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Full text of "A system of surgery (Volume 4)"

THE 

ABNER WELLBORN CALHOUN 

MEDICAL LIBRARY 

1923 



• 







Class- 



Bock_ 



PRESENTED BY 



fotcls JlccjX^ 



A 

SYSTEM 

O F 

SURGERY- 

B Y 

BENJAMIN BELL, 

MEMBER OF THE ROYAL COLLEGES OF SURGEONS 

OF IRELAND AND EDINBURGH, 

ONE OF THE SURGEONS TO THE ROYAL INFIRMARY^ 

AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. 

ILLUSTRATED WITH COPPERPLATES. 

VOLUME IV. 
THE THIRD EDITION. 




EDINBURGH: 

Printed for CHARLES ELLIOT, Edinburgh ; 

C. ELLIOT & T. KAY, N° 332. Strand j and 

G. G. J. & J. ROBINSON, London. 

M,DCC,LXXXIX, 



CONTENTS. 

o 

CHAPTER XXVII. 
Seel. XIX. Additional Remarks on Dif- 
eafes of the Eyes, - i 

CHAP. XXVIIL 

Of the Diseases of the Nose and Fau- 
ces, - - 63 

Seel. I. Anatomical Defcription of the 

Nofe and Fauces, - - 63 

Seel. II. Of Hemorrhagies from the 

Noflrils, - 70 

Seel. III. Of an Ozena, - 76 

Secfl. IV. Of Imperforated Noftrils, 85 

Sect. V. Of Polypi in the Nofe and 

Fauces, - 90 

Seel. VI. Of Extirpation of the Tonfils, 132 

Seel. VII. Of the Extirpation of the 

Uvula, - - 142 

Seel. VIII. Of Scarifying and Foment- 
ing the Throat, - - 146 
A2 CHAP. 



iv CONTENTS, 

Page 

CHAP. XXIX. 
Of the Diseases of the Lips, - 149 
Sett. I. Of the Hare Lip, - 140 

Sedl. II. Of the Extirpation of Can- 
cerous, Lips, - h 176 

CHAP. XXX, 

Of the Diseases o/"//^ Mouth, 181 

Se£t. I. Anatomical Remarks * - \ 8 1 
Se6t II. Of Dentition, - loi 

Seel. III. Of the Derangement of the 

Teeth, - . 19? 

Sed. IV. Of Gum Boils, *. 203 

Sed. V. Of Abjcejfes vn the Antrum 

Maxillare, ■■- - 209 

Seel. VI. Of Excrefaences on the Gums, £24 
Sed. Vll. Of Loofe Teeth, \\ fW.\ 230 
Sed. VIII. OfCleanfmg the Teeth, 1236 
Sea. IX. Of Toot hack, - 24S 

§ 1 . Of Toot hach from the Nerve be- 
ing laid bare, and of the various 
Methods of ' extracting Teeth, 250 
§ 2. Of Toot hach from Inflammation, 302 
§ 3. Of Toot hach from AffeCiions of 
diftant Parts, - "• 308 

Sea, 



CONTENTS. {f 

Page 

Se<5l. X. Of Tr an/planting Teeth, 3 1 3 
Sedl. XI. Of the Ranula, - 325 

Sed. XII. Of Ulcers of the Mouth and 

Tongue, and Extirpation of the 

Tongue, - - 329 

Sed. XIII. Of the Divifton of the Fre- 

num Lingua, - ~ 33& 

Sea. XIV. Of the Divifton of the Pa- " 

rot id Duel, - - 338 

CHAP. XXXT. 

Of the Diseases of the Ears, and Ope- 
rations praclifed upon than, 343 
Sea. I. Of Deafnefs, - 343 
§ 1, Of an Imperforated Meatus Au- 
dit or ius, - - 347 
§ 2. Of Extraneous Bodies impacled 

in the Ear, - - 349 

§ 3. Of Excrefcences in the Meatus 

Audit onus, - _ -1^2 

§ 4. Of Deafnefs from Wax colkcled 
in the Ears, - - 355 

Sea. II. Of perforating the Lobes of 
the Ears, - - 362. 

CHAP. 



<?i CONTENTS, 

Page 

CHAP. XXXII. 

Of the Wry Neck, - 366 

CHAP. XXXIII. 
Of Diseases of the Nipples, - 371 

CHAP. XXXIV. 
Of Issues, - - 376 

CHAP. XXXV. 

Of Inoculating for the Small- 
pox, - - 385 

Explanation of the Plates, - 390 



A 



A 

TREATISE 

O N T H E 

THEORY and PRACTICE 

O F 

SURGERY. 

CHAPTER XXVII. 

SECTION XIX. 

Additional Remarks on Difeafes of the Eyes* 

IN the lad volume of this work, I treated 
fo fully of the difeafes of the eyes, that 
it was not my intention to fay any thing 
farther upon them : But fmce the publi- 
cation of that volume, a foreign oculiftj 
Mr Jean Francois Pellier, having appeared 
in this country, where he has already ac- 
; Vol. IV. B quired 



io Difeafesof the Eyes. Ch. XXVIL 

quired much reputation, I confider it as a 
neceffary addition to the chapter on thefe 
difeafes, to communicate fuch parts of 
Mr Pellier' s praclice as appear to be of 
importance. PofTefling the advantages of 
a liberal education, a found judgment, and 
much experience, Mr Pellier has been ena- 
bled to fugged improvements in the treat- 
ment of almoft every difeafe to which the 
eyes are liable; and an uncommon degree 
of fteadinefs, conjoined to a quick eye- 
fight, give him a command of himfelf 
and a facility of operating which is not 
often attained. I think it proper like wife 
to remark, that Mr Pellier communicated 
his knowledge of the difeafes of the eyes 
in the moft candid manner ; which puts 
it in my power to lay his obfervations be- 
fore the Public, he having given me per- 
miflion to do fo. 

While, by giving an early account of 
material improvements, I thus acquit my- 
felf of an obligation to the Public, I at the 
fame time embrace, with much fatisfaclion, 
the opportunity which it affords of an- 
nouncing 



Sea. XIX. Difeafes of the Eyes. 1 1 

iiouncing the merit of an operator, who, 
although a (tranger and as yet not much 
known in this country, is perhaps one of 
the beft oculifts now in Europe. 

In the firft place, I (hall mention what 
I have learned of Mr Pellier's practice ; 
and (hall then offer fuch remarks as occur 
to me upon it. 

On the fubject of the cataract his obfer- 
vations are particularly valuable. By at- 
tentive examination he can almoft in every 
inftance fay whether a cataract is hard, 
fomewhat foft, or altogether fluid j and as 
his method of operating varies according 
to thefe circumflances, it is of importance 
to be able to determine a. priori with re- 
gard to them. He can alfo afcertain whe- 
ther a cataract is of a large or fmall fize ; 
by which he is often directed in the diffe- 
rent fteps of the operation. 

I know that thefe are circumflances 
which practitioners in general confider it 
as impoflible to judge of with any degree 
of precifion, particularly with refpect to 
the confidence of cataracts ; and I mult 
B 2 ac- 



12 Difeafes of the Eyes. Ch. XXVII. 

acknowledge, that I was clearly of this 
opinion, till of late that I was convinced 
of the contrary, not by Mr Pellier's afler- 
tions alone, but by different proofs of the 
fact. I aflifted Mr Pellier in different cafes 
where the cataract was extracted : in . all 
of them he previoufly foretold the confid- 
ence and fize of the cataract with perfect 
confidence j and in every inftance hi& prog- 
noils was precife and accurate. I am cre- 
dibly informed, too, that this happened 
with other practitioners in whofe preftnce 
he operated in different parts of this coun- 
try. 

Mr Pellier's definition of a cataract is, 
That it is a morbid affection attended with 
different degrees of opacity either in the 
lens itfeif ; in the fmall quantity of fluid 
with which the lens is fun ounded ; or in 
the capfule which contains it. 

He diftinguifhes feveral varieties of ca- 
taract, which in practice ought to be kept 
in view. 

The three principal varieties which he 

mentions 



Sef\. XIX. Difeafes of the Eyes. 13 

mentions are, the true or curable cataract; 
the mixed or doubtful kind ; and the falfe 
or incurable. 

1 . The curable, or what he terms the true 
cataract, is known by the pupil retaining 
its natural power of contracting and dila- 
ting in full perfection, while the patient is 
at the fame time able to diftinguifh the 
light of a candle, or of any other luminous 
body, and even certain bright colours, fuch, 
as red, green, &c. 

2. The mixed or doubtful cataract is at- 
tended with a weak feeble contraction and 
dilatation of the pupil, and the patient can 
fcarcely diftinguifh light from darknefs. 
Along with an opacity of the cryftalline, 
this is fuppofed to be attended with an af- 
fection of the retina, or of fome other part 
of the eye. 

3. In the falfe or incurable cataract, 
along with an opake ftate of the lens, there' 
is evidently a difea fed ftate of the pupil, 
which remains always immoveable to 
whatever degree of light it may be expofed, 
at the fame time that the patient does not 

B 3 diftinguifh 



I 4 Difeafes of the Eyes. Ch. XXVII. 

diftinguifh between the raoft brilliant light 
and perfect darknefs. 

Cataracts may be either fimple or com- 
pound, or they may be complicated with 
other affections. 

i. A fimple cataract is a mere opacity of 
the cryftalline lens, all the other parts of 
the eye remaining perfectly found. 

2. A cataract is faid to be of a compound 
nature, when blindnefs is produced by an 
opake flate of the body of the lens, of the 
liquor which furrounds it, and of the cap- 
fule. 

3. The difeafe is confidered as complex, 
when it is conjoined with other affections 
of the internal parts of the eye ; the moft 
frequent of which is an amaurosis. 

It is not unfrequently, too, attended with 
a diffolution of the vitreous humour, and 
fometimes with an opacity of it. This va- 
riety of the difeafe is for the moft part 
produced by violent inflammation. It is 
eafily diftinguifhed by thofe accuftomed 
to an attentive examination of the eye; 
and it is particularly neceffary for opera- 
tors 



Sea. XIX. Difiafis of the Eyes. 15 

tors to be well acquainted with it ; for no 
operation, neither extraction nor depref- 
{ion, mould be ever advifed for it. The 
operation has never in any inftance of this 
fpecies of cataract been known to fucceed ; 
and for the inoft part, Mr Pellier obferves, 
it is productive of very dreadful pain, and 
the mod violent degree of inflammation 
that he ever met with. In general, too, 
the pain and inflammation thus induced 
remain fixed and permanent, without 
yielding in any degree to the remedies em- 
ployed for it. 

Cataracts are fometimes attended, too, 
with an imperforated iris ; in which cafe, 
as no light can pafs to the bottom of the 
eye, there is no degree of vilion whatever; 
and at other times they are complicated 
with adhefions, either to the iris, or to the 
capfule of the vitreous humour. Preter- 
natural adhefions of the lens to the cap- 
fule of the vitreous humour can fcarcely 
be diftinguiihed by the eye ; but they are 
very commonly met with where the dif- 
eafe has been originally produced by, or 
B 4 at- 



1 6 Difeafes of the Eyes. Ch. XXVII. 

attended with, much inflammation ; and 
they always render the operations of ex- 
traction and couching difficult. It is this 
kind of adhefion, Mr Pellier imagines, 
which prevents the operation of couching 
from fucceeding fo frequently as it other- 
wife might do ; for when it takes place 
in any degree, the cataract, he fuppofes, 
will always rife again on the needle being 
removed from it. 

In forming an opinion of cataracts from 
the feat of the difeafe, there are different 
circumftances which require attention. 

1. It often happens, as we have already 
remarked, that the lens only is affected. — * 
This variety of the difeafe is moil frequent, 
."Mr Pellier obferves, in adults, and efpe- 
cially in old age. 

2. When the opacity is feated in the 
capfuie of the lens, if the anterior part of 
it only is difeafed, it appears to be remark- 
ably white, and to be placed very conti- 
guous to the iris ; while, on the contrary, 
if the pofterior part of it only is affected, 
it is commonly of a grey colour, and the 
opacity appears to be deeply feated. 

It 



Sect. XIX. Difenfes of the Eyes, 17 

It fcmetimes happens, both after the 
operation of extraction and couching, that 
in the courfe of ten or twelve days, the 
capfule of the lens, which at firft was per- 
fectly found, becomes quite opake. — This 
variety of the difeafe Mr Pellier terms the 
Cataracte Secondaire. 

3. When the body of the lens and its 
capfule are both opake, it commonly hap- 
pens that the cataract is foft or even alto- 
gether fluid. In this cafe, much attention 
is neceffary in the operation of extraction, 
to prevent the capfule from burfhing : a 
degree of nicety, Mr Pellier obferves, which 
thofe not much accuftomed to this branch 
of practice can feldom arrive at, but which 
is very practicable with thofe who have 
had much experience in it. 

4. In fome inftances cataracts appear to 
proceed from a partial affection of the lens, 
fmall opake fpots being obferved in it, 
while the reft of it remains found. In 
this cafe, vifion is always mcft perfect in 
an obfcure light wdien the pupil is mod 
dilated. 

In 



1 8 Blfeafes of the Eyes. Ch.XXVII. 

In judging of cataracts from their con- 
fidence, there are three circumftances 
which more particularly require atten- 
tion. 

i. When a cataract is of a firm confift- 
ence, it is in almoft every inftance of a 
brown colour ; it appears in general di- 
rectly behind the iris, and not fo deep as 
the lens is ufually placed, and the pupil 
dilates and contracts very {lowly. 

2. When it is fluid, it is not commonly 
white, but rather of a cream colour, fome- 
what refembling purulent matter ; and 
for the moft part in this variety of the 
difeafe the globe of the eye appears full, 
and fomewhat larger than ufual. 

3. It fometimes happens, Mr Pellier ob- 
ferves, that along with this fluid flate of a 
cataract, the capfule is confiderably thick- 
ened. To this he gives the appellation of 
the Cyftic Cataract. 

The colour of a cataraft is another point 
of importance. 

1. We have juft obferved, that a thin 
fluid cataract is for the moft part of a 

cream 



Sea. XIX. Difeafa of the Eyes. 1 9 

cream colour ; but in that variety of the 
difeafe which is obfervcd in children at 
birth, although it is always fluid, the co- 
lour is almoft always a milk-white. In. 
general, however, at other periods of life, 
a white cataract is of a cheefy confidence. 

2. When a cataract is of a yellow colour, 
a fmall portion of the lens commonly re- 
mains hard, the reft of it being diUblved 
into a thin tranfparent fluid, forming that 
variety of the difeafe ufually termed the 
Hydatid Cataract. 

3. Although a black cataract is not a 
common occurrence, Mr Pellier fays he 
has met with different inftances of it. The 
only difeafe for which it may be miftakea 
is the gutta ferena ; but it may be diitin- 
guifhed from it by attention and obferva- 
tion. In the gutta ferena the difeafe for 
the moft part comes on fuddenlv, the pu- 
pil is of a deep black, it remains immove- 
able in every degree of light, and the pa- 
tient cannot difhnguifh colours or the 
cleareft light from perfect darknefs ; where- 
as, in the black cataract, the accemon of 

blind- 



20 Difeafes -of the Eyes. Ch. XXVII. 

blindnefs is commonly flow and gradual ; 
the pupil contracts and dilates according 
to the degree of light to which it is expo- 
fed ; the bottom of the eye is of a dark 
colour, but not of fuch a deep black as in 
the gutta ferena ; and the patient can di- 
ftinguifh light and vivid colours. In fhort, 
the fymptoms of this variety of the difeafe 
are exactly the fame with thofe of the 
common cataract ; only, inftead of being 
white, the opacity is black. 

With refpect to the maturity or ripe- 
nefs of a cataract, Mr Pellier pays no re- 
gard either to the colour or confiftence of 
the lens : He always confiders the opera- 
tion as proper, when the opacity has pro- 
ceeded fo far as to deprive the patient of 
fight, when it is not complicated with 
fome other incurable difeafe, and when 
the habit of body is good. He prefers 
the method of cure by extraction, except- 
ing in a few cafes where the pupil is ex- 
tremely fmall, when he operates by de- 
preflion. He always prepares his patients 
for the operation, by confining them to a 

low 



i,,vn<; xxx ix 




Sea. XIX. Dlfeafes of the Eyes. 21 

low diet for five or fix days ; by giving 
two or three dofes of falts and fenna ; and 
when they are plethoric, he takes away ten 
or twelve ounces of blood. 

In extracting the cataract:, he makes the 
incifion of the cornea in the ordinary place 
and of the ufual fize ; but he has fome pe- 
culiarities in his method of doing it. 

Inftead of placing his patient with his 
face oppofite to a clear light, he feats him 
with his fide towards it. If he is to ope- 
rate upon the left eye, he ufes his right 
hand, and the right fide of the patient is 
placed towards the window. He always 
ufes his left hand in operating upon the 
right eye ; and in this cafe t,he patient is 
made to fit with his left fide towards the 
light. 

The patient being feated with the eye 
which is not to be operated upon tied 
down with a bandage, an affiflant fupports 
his head behind, while at the fame time he 
fixes the eye with the fpeculum, fig. 5. 
Plate XXXIX. The figure reprefents the 
inftrument of the full fize. It is made of 

wire ; 



22 DifeafesoftheEyes. Ch. XXVIL 

wire ; and it may either be of gold, lilver, 
or any other metal. The head being fixed 
by preffing it againft the bread with one 
hand under the chin, the affiftant takes 
this infixument in the other ; and placing 
the round curvature A upon the upper 
eye-lid immediately behind the tarfus or 
cartilage, he muft by gentle gradual pref- 
fure fix the eye above, while the operator 
with the fore and middle fingers of his 
left hand, when the operation is to be 
done upon the left eye, muft fix it below, at 
the fame time that he draws down the un- 
der eye-lid. In ufing this fpeculum the 
tipper eye-lid is forced almoft entirely in- 
to the orbit, but it immediately returns to 
its natural fituation on the inftrnment be- 
ing withdrawn. 

The eye being thus fixed, the knife fig. i . 
Plate XXXIX. fixed in its handle, muft be 
put into the operator's right hand, who 
now divides the cornea in the ufual man- 
ner : but when the point of it comes op- 
posite to the pupil, if the capfule of the 
lens is to be divided, Mr Pellier has ar- 
rived 



Setft. XIX. Difeafes of the Eyes. i% 

rived at fuch dexterity in this operation, 
that he plunges the point of the knife 
through the pupil into the lens j and with- 
drawing it gently, he carries, the point of 
it forward to the oppofite fide of the eye, 
and finifhes the operation in the ufual way* 
But in making the latter part of the inci- 
fion, he is very attentive to the preffure 
made by the fpeculum, which he defires 
the afliftant to remove entirely before the 
incifion is completed, in order to prevent 
the vitreous humour from efcaping; 

This being done, the eye-lids are im- 
mediately fhut ; and while they are in this 
flate, a flow, gradual preffure is made up- 
on the eye-ball, with the flat end of the 
inflrument which he terms a Curette, fig. i. 
Plate XL1I. which is placed immediately 
above the tarfus of the upper eye-lid. As 
the accefs of light to the eye is thus pre- 
vented, the pupil remains in a flate of di- 
latation, by which the lens is more eafily 
prefTed out than it otherwife could be 5 
and if the preffure be applied in a cautious 

man- 



24 Difeafes of the Eyes. Ch. XXVII. 

manner, no part of the vitreous humour 
is ever forced out. 

When the cataract does not come out 
entire, which is fometimes the cafe, or 
when it is found to adhee to the conti- 
guous parts, the end of the curette is in- 
troduced through the pupil, and with it 
any adhefions that occur are gradually fepa- 
rated; at the fame time that any detached 
pieces of the lens are turned out through the 
opening in the cornea : Or, inftead of the 
curette, the ciftatome fig. 3. Plate XL. is 
fometimes employed for feparating fuch 
adhefions. 

In the courfe of this operation, it fome- 
times happens that the iris is forced too 
much forward into the anterior chamber of 
the eye, or even altogether through the in- 
cifion in the cornea. With a view to pre- 
vent the bad effects which might refult 
from this, Mr Pellier iniinuates the flat fide 
of the curette into the wound in the cornea, 
fo as to prefs the iris into its natural fitu- 
ation. 

This is the ufual method in which Mr 
Pellier performs this operation j but cir- 

cumftances 



Sea. XIX. Difeafes of the Eyes. 25 

cumftances fometimes occur which require 
fome peculiarity of management. The 
mod material of which are thefe : When 
he has reafon to conclude that the cata- 
ract is in a fluid ftate without any opacity 
of the capfule, inftead of making any open- 
ing into the cornea of the ufual fize, he 
introduces a fharp-pointed knife, fomewhat 
convex on the back, into the inferior part 
of the tranfparent cornea at a proper di- 
ftance from the. iris ; and having made an 
incifion of about the tenth part of an inch 
in length, he pufhes the point of the inftru- 
ment upwards till it comes oppofite to the 
pupil, when he carries it cautioufly on till 
it reaches the lens ; and having now made 
an opening in the capfule fufficiently large 
for difcharging the fluid contained in it, 
he withdraws the inftrument with the 
fame caution with which it was introdu- 
ced, and in this manner the operation is 
finifhed : as the cataract being in a ftate 
of fluidity, it pafles eafily off without any 
prefTure. 

When, again, along with a foft or fluid 
Vol. IV. c cat*. 



46 Difeafes of the Eyes. Ch. XXVII. 

cataract, there is reafon to fuppofe that 
any part of the capfule is opake, or even; 
where the capfule alone is fappofed to be 
difeafed, he carefully avoids opening it or 
burfting it in the courfe of the operation : 
in either of thefe events, he fays, it would 
be with difficulty extracted. He therefore 
by flow gradual prefTure wich the curette, 
in the manner we have mentioned, forces 
out the lens, contained, as he imagines, in 
its capfule or cyft ; and he does it, he fays, 
in every inflance without forcing out any 
part of the vitreous humour. In fome 
cafes, however, he finds it necefTary to 
introduce the end of the curette through 
the pupil, and to feparate the capfule of 
the lens from the contiguous parts ; but 
even this, he fays, does no harm to any 
part of the eye. The importance of our 
being able to judge from the appearances 
of a cataract of the real ftate of the difeafe 
is therefore fufficiently obvious, from the 
difference which this variety of it requires 
in the method of operating. 

In extracting the cataract, it is a matter 

of 



Sed. XIX. Difeafes of the Eyes. i 7 

of the higheft moment to avoid the iris 
with the knife ; but as this is extremely 
difficult in eyes that are not very promi- 
nent, in fuch cafes Mr Pellier employs a 
knife with that fide of it convex which 
panes next to the iris. One of thefe in- 
ftruments is reprefented in Plate XXXIX. 
fig. 2. In every other refpect it is the 
fame with the knife which he ufes in or- 
dinary cafeSj reprefented in fig. I. of the 
fame plate* 

In the courfe of this operation^ it fome- 
times happens that the aqueous humour 
efcapes in too great quantity before the 
point of the knife is carried acrofs the eye 
fo as to penetrate the oppofite fide of the 
cornea : When this takes place, which it 
often does when the hand of the operator 
is not perfectly fleady, as the iris is apt 
to pafs in before the point of the inflru- 
ment, Mr Pellier advifes the knife to be 
withdrawn, and the other knife, fig 3 with 
a blunt or probe-point, to be introduced 
at the opening in the cornea : and the 
point being flowly carried over to the op- 
C 2 polite 



a 8 Difccifes of the Eyes. Ch. XXVII. 

polite fide of the eye, an incifion is there 
to be made, either with the other fharp- 
pointed knife or with a common lancet, 
fufficiently large for letting out the blunt 
point of the other ; when the operation is 
to be nnifhed in the ufual way, by pufliing 
it forward, and making a kind of femi- 
circular incifion in the under part of the 
cornea. 

As foon as the cataract is extracted, it is 
the common practice to prefent a watch 
or fome other object to the patient, with 
a view to difcover the fuccefs of the ope- 
ration. In fome inftances Mr Pellier has 
been forced to confent to this, but he does 
not approve of it. Inftead of this, he im- 
mediately clofes the eye-lids, and covers 
each eye with a fmall bag of fofc old li- 
nen or cotton about half filled with foft 
fine wool. Thefe bags are applied dry, 
and are fixed with pins to a circular ban- 
dage of old linen pafTed round the fore- 
head, which again is kept firm in its fitua- 
tion by a flip of the fame linen made to 
pafs beneath the chin and over the upper 

pare 



Sect. XIX. Difeafes of the Eyes. 29 

part of the head ; care being taken to fix 
them both with pins to the night-cap be- 
low. 

The patient is now to be undrefTed, and 
with as little exertion as pofftble mould be 
laid in bed, upon his back with his head 
very little elevated : and in this fituation 
he mould remain with as little variation 
as poffible during the fir ft fix or eight 
days, as it tends more than any other he 
can be placed in to a fpeedy cure of the 
wound in the cornea. In the courfe of a 
few hours after the operation, Mr Pellier al- 
ways advifes blood-letting to the extent of 
eight or ten ounces, excepting in low ema- 
ciated conftitutions. The patient is kept 
upon a low diet. He gives an opiate ; but 
prefers fmall dofes frequently repeated to 
the giving a large dofe at once, which often 
produces ficknefs aifd vomiting, which 
fhould by all means be guarded againfl ; 
for nothing fo readily hurts the eye as the 
exertion of vomiting, coughing, and freez- 
ing. For which reafon he does not admit 
Cj of 



30 Difeafes of the Eyes. Ch. XXVII. 

of tobacco being ufed in any form, for the 
firft eight or ten days. 

The belly mould be kept moderately, 
open by gentle purgatives, and on the 
fourth or fifth day the dreffings may be re- 
moved ; and after clearing the eye of any 
matter that may have collected, and the 
eye-lid being cautioufly lifted to examine 
the flate of the wound, the fame kind of 
bandage mud be applied again. From 
this time forward the drefling fhould be 
renewed every fecond day, and in ten or 
twelve days from the operation the eye 
fhould be bathed before the new bandage 
is applied with a weak faturnine folution ; 
but till this period warm milk and water 
is confidered as preferable. About the end 
of the third week the bags of wool, after 
having been gradually lefTened, may be 
taken away entirely, and a piece of green 
filk put over the eyes inftead of them. If 
no interruption occurs to the cure, the diet 
may be made gradually better ; and when 
one eye only has been operated upon, Mr 
Pellier commonly allows the patient to go 

abroad 



Se(5l. XIX. Difeafes of the Eyes. 3J 

abroad at the end of the fourth week, but 
never fooner ; and even then the eyes are 
directe 1 to be well covered : But when 
both eves have been cut, he advifes a con- 
finement of at lead fix weeks. 

This is the plan of treatment which Mr 
Pellier purfur?s in ordinary cafes ; and he 
attribuces much of the fuccefs with which 
his operations are attended to a rigid ob- 
fervation of thefe regulations. Bur where 
there is a particular tendency in the fyftem 
to inflammation, remedies of a different; 
kind are required. 

The eye becomes in fome cafes fo much, 
inflamed even in the courfe of a few hours 
from the operation, that one blood-letting 
does not prove fufEcient. In this cafe he 
advifes leeches to be applied to the neigh- 
bourhood of the eye ; and if a fecond or 
third general evacuation is necelTary, he dU- 
reds the blood to be taken from the foot, as 
by experience he finds this to prove more 
fuccefsful than taking it from the arm or 
neck. The patient is defired to drink plen- 
tifully of Arabic emullion, with a large pro- 
C 4 portion, 



32 Difeafes of the Eyes. Ch. XXVII. 

portion of nitre. The pediluvium frequent- 
ly repeated is fuppofed to prove very fer- 
viceable. And, for the removal of that vio- 
lent pain which inflammation fupervening 
to this operation commonly excites, nothing 
that has yet been tried, he thinks, anfwers 
fo well as a liniment coinpofed of the 
white of an egg and powdered alum beat 
for a considerable time together : a little of 
which fhould be applied to the eye every 
two hours between two plies of a bit of 
foftold linen. Befides affording relief from 
pain, it tends more effectually than any 
other remedy to flop the progrefs of in- 
flammation ; infomuch, that Mr Pellier 
employs it in every cafe as foon as the eye 
begins to inflame. 

Inflead of alum, he fometimes adds to 
the white of an egg three grains of white 
vitriol, and as much of faccharum Saturni 
difTolved in a fpoonful of rofe water; and 
the whole being well beat together till it 
puts on the appearance of white froth, a 
little of this is inferted between the eye- 
lids with a fmall pencil three or four times 

a-day, 



Sect. XIX. Difeafes of the Eyes. 33 

a-day, at the fame time that the eye-lids 
are covered with a fmall bag of thin 
linen in which fome of it is contained. 
When the heat and pain attending the in- 
flammation begin to abate, he advifes a. 
poultice compofed of a ripe apple well 
boiled, with the water prefled out of it, 
and a fmall quantity of camphor and pow- 
dered faffron added to it. 

By perfevering duly in thefe means the 
inflammation is commonly at laft removed. 
It is otherwife, however, in fome inftances: 
infomuch, that notwithftanding the ut- 
moft attention, every fymptom is aggra- 
vated ; the veflels of the tunica conjunctiva 
become extremely turgid ; the eye-lids 
fwell to a confiderable fize ; and the pain, 
which before was fevere, is now infupport- 
able. In this fituation, nothing has ever 
any effect in flopping the progrefs of the 
inflammation but local blood-letting car- 
ried to a confiderable extent by incifions 
made in the affected parts. For this pur- 
pofe the mere divifion of the turgid veflels 
with a lancet or fmall fcalpel fometimes 

anfwers ; 



34 Difeafes of the Eyes. Ch. XXVII. 

anfwers ; but in general it proves more fuc- 
cefsful-to take away fmall portions from 
different parts of the internal furface of 
the eye-lids with fmall convex fciffars, fuch 
as is reprefented in Plate XXXIX. fig. 4. 
This, Mr Pellier obferves, feldom fails of 
giving immediate relief; and he has never 
afterwards found it produce any inconve- 
nience. The ftate of the eye too being 
very critical, no remedy mould be omitted 
that affords any chance of obviating the 
prefent danger ; for if this be not quickly 
done, fuppu ration will foon take place ei-. 
ther in the coats of the eye, or in one or 
both of the chambers. 

When matter is evidently formed, a fre- 
quent ufe of warm emollient fomentations, 
applied particularly to the eye by means 
of a funnel of pafleboard, will fometimes 
produce a flow difcharge of it at the inci-r 
fion in the cornea : but when this does 
not fucceed in the fpace of eight and forty 
hours, no more time fhould be loft ; the 
matter fhould be evacuated by an incifion 
made in the mofl depending part of the 

abfcefs, 



Sea. XIX. Bifmp of the Eyes. 35 

abfcefs, when it is feared in the fubftance 
of the cornea ; or, by opening the lips of 
the incifions made for extracting the cata- 
ract, when the collection is in either of the 
chambers of the eye. By this means the 
patient will be immediately relieved from 
pain, while at the fame time he will receive 
the only chance of preferving the ufe of 
his eye. 

There is ftill another difagreeable occur- 
rence to which patients are liable during 
the firft two or three weeks after this ope- 
ration ; a kind of ftaphyloma, or herniary 
fweliing, formed by the iris, or fome other 
part, being forced out at the opening in 
the cornea, either by violent coughing, 
fneezing, or fome other effort ; and in fome 
inftances, by expcfing the eye too foon and 
too frequently before the cicatrix is fuffi- 
ciently firm for refitting the preffare thus 
produced upon it. When the fweliing 
which thus takes place is fmall, it may 
commonly be removed by touching it fre- 
quently with a fmall pencil dipped in Gou- 
lard's extrad of lead,, concentrated by eva^ 

poration, 



36 Difeafes of the Eyes. Ch. XXVII. 

poration, or in any mild antimonial ef- 
charotic : An attempt, Mr Pellier obferves, 
that may be made with perfect fafety, if 
care be taken to prevent the cauflic from 
hurting the reft of the eye, by touching 
the difeafed part only with it, and immer- 
fing the whole eye immediately in warm 
milk, or in fome warm emollient decoc- 
tion. But when the difeafe is farther ad- 
Tanced, and if it be of a firm folid nature, 
it anfwers better to remove the protruded 
part entirely either with the knife or the 
fcifTars ; or if it appears to be any part of 
the aqueous humour contained in a thin 
membranous production, as is fometimes 
the cafe, all that is in general neceffary is, 
to make an incifion into it with a lancet 
of a fize fufEcient for difcharging it. It 
is fcarcely neceffary to obferve, that after 
either of thefe operations, the parts muft 
be treated with much attention, other wife 
inftead of proving ferviceable, they may 
do harm. A Uriel antiphlogiftic regimen 
muft be obferved. The eye fhould be 
lightly covered, either with a fmall bag, 

fuch 



Sea. XIX. Difeafes of the Eyes. . 37 

fuch as we have mentioned above, filled 
with fofc wool, or with a comprefs of old 
linen foaked in a weak folution of fac- 
charum Saturni. 

Mr Pellier's method of extracting the 
cataract, which I have thus endeavoured to 
defcribe, with his treatment of the confe- 
quences which fometimes enfue from it, is 
the remit of much experience, and ufual- 
ly proves more effectual than any other 
with which we are acquainted. Much of 
Mr Pellier's fuccefs undoubtedly proceeds 
from his fuperior dexterity in performing 
the operation ; but much of it alfo depends 
upon the minute attention he pays to every 
cafe for a confiderable time after the ope- 
ration. In ordinary practice, and efpeci- 
ally with the moft part of itinerants, it is 
commonly fuppofed, if the operation be 
properly performed, and if the cataract 
comes away eafily, that very little more is 
neceffary on the part of the operator ; but 
it is much otherwife with Mr Pellier, who 
considers the after treatment as fo effential, 
that it is with difficulty he is ever prevail- 
ed 



3 8 DjfeafesoftheEyes. Ch. XXVlL 

ed upon to operate where he cannot have 
the fubfequent management of the cafe for 
two or three weeks : And by conftant and 
afliduous attention, he is ofcen able to ob- 
viate fymptoms which might otherwife 
prove alarming ; and which, in many in* 
fiances, might even render operations a- 
bortive which would otherwife be attend- 
ed with the mod complete fuccefs. Of 
this I have feen different inftances. 

In a former part of this work, I entered 
into a full difcumon of the refpective me- 
rits of the two operations of couching and 
extracting the cataract j and I then endea- 
voured to eftablifh the preference of the 
former : But if experience fhows, that Mr 
Pellier's method of operating is attended 
with more permanent advantages, I fhall 
be very ready to retract my opinion ; for 
which purpofe, I fhall carefully attend to 
the confequences of thofe operations which 
he has performed in this country ; and -as 
the public will probably be interefted in 
them, I fhall at fome future period perhaps 
communicate the event of them. 

There 



PUA'l'l'.; . M, . 




FIG. 



Sea. XIX. Difeafes of the Eyes, 39 

There are two points of importance in 
this operation, with refpect to which I dif- 
fer in opinion from Mr Pellier. When he 
confiders it as proper to divide the capfule 
of the lens, he frequently does it, as we 
have already obferved, by infinuating 
through the pupil the point of the fame 
knife with which he makes the incifion of 
the cornea, even before the incifion is 
completed. 

This may poffibly be done with fafety 
in every inftance by ftich a very dexterous 
operator as Mr Pellier : but as moil prac- 
titioners, by imitating him, would run the 
rifk of hurting the iris, the practice mould 
not be encouraged ; for when the capfule 
of the lens is to be divided, it is furely bet- 
ter to do it after the incifion of the cornea 
is finilhed, by lifting up the flap, and paf- 
fing in the end of the blunt probe repre- 
fented in Plate XXX. fig. 5. Vol. III. or 
of the ciftatome, Plate XL. fig. 3. 

The other point to which I allude re- 
fpects the practicability of extra cYmg the 

capfule 



40 Difeafes of theZyes. Ch. XXVlh 

capfule of the lens, without doing any ma- 
terial injury to the eye. 

When the cataract appears to be of a 
firm confidence, and when the difeafe is 
fuppofed to be confined entirely to the lens 
itfelf, Mr Pellier frequently opens the cap- 
fule in the manner 1 have juft defcribed, 
with a view to allow of a more eafy ex- 
traction of the lens ; and in this cafe he 
admits that the capfule remains in the 
eye : But when he finds, after an opera- 
tion, that the capfule of the lens becomes 
opake, or if he obferves that any part of 
it has been previoufly in a flate of opacity, 
he advifes it to be cautioufly extracted with 
fmall forceps : And again, in every cafe 
where he fufpects the cataract to be fluid, 
forming what he calls the Cyilic or Hy- 
datid Cataract, he avoids the di virion of the 
capfule, and advifes the lens to be taken out 
included in it; which he fays may be done 
in the manner we have mentioned, by ma- 
king an equal and gradual prefTure upon 
the ball of the eye immediately after the 
di virion of the cornea ; or by feparating 

any' 



Sea. XIX. Difeafes of the Eyes. 41 

any adhefions which take place between 
the capfule of the lens and the contiguous 
parts, with the curette pafTed through the 
pupil. 

I have not indeed feen Mr Pellier ex- 
tract the capfule of the lens after removing 
the lens itfelf ; for no cafes requiring it 
occurred during his refidence here : I re- 
ceived, however, full information of his 
method of doing it, by introducing fmall 
forceps at the pupil. But as I cannot ima- 
gine how this can be done without inju- 
ring the eye materially, I muft ftill retain 
the opinion I formerly advanced of it, till 
I have evident proofs of its being practifed 
with advantage* : And whenever thefe are 
offered, I mall receive them with much fa- 
tisfaction, as it would in many inftances 
be a material improvement of this opera- 
tion. 

We have now to confider the poflibility of 
extracting the capfule entire along with the 
lens : Several practitioners in this country 
had opportunities of feeing Mr Pellier ex- 

Vol. IV. D tract 

* Via". Vol. III. page 442. 



42 Difea/es of the Eyes. Ch. XXVIL 

tract cataracts, as they fuppofed, in this 
fituation. I faw him operate in two inflan- 
ces of this kind, where he, as well as feve- 
ral others, imagined that the real capfule 
was taken out along with the lens ; but as 
I entertain a different opinion on this fub- 
ject, it is proper to ftate the reafons which 
have led me to adopt it. 

I. The capfule of the vitreous humour, 
and that which contains the lens, are fo 
intimately connected together, that it is 
difficult, or perhaps impoffible, for the belt 
anatomifl to determine whether they arc 
feparate productions or not : At leaft they 
are fo intimately connected, that they ap- 
pear to be formed of the fame fubftance, 
the cryftalline lens being furrounded with 
a coat which feems to be a thin lamella of 
that which forms the capfule of the vitre- 
ous humour. The contrary, I know, has 
been alleged ; but whoever will make the 
experiment, will find that the capfule of 
the lens has exactly the appearance which 
I have mentioned. It appears to be a pro- 
duction of the other j and they cannot be 

feparatecl 



Sect. XIX. Difeafcs of the Eyes. 43 

feparatcd without tearing or deftroying 
fome part of one or both of them : Now, if 
this is the cafe, when the contents of the eye 
are all laid open, and when all the atiiftance 
can be got that nice diffection affords, it 
appears to me impoffible that they mould 
be feparated in the operation of extracting 
the cataract without injuring the reft of the 
eye, and particularly the vitreous humour, 
very materially. 

2. In performing this part of the opera- 
tion, viz. in attempting to extract the cap- 
lule of the lens entire, Mr Pellier does it 
by means which do not appear adequate to 
the intended effect. He does it, in mofl 
inftances, by making a gradual equal prefc 
fure over the ball of the eye, and not by 
the introduction of forceps. Now it is dif- 
ficult to conceive in what manner preffure 
applied to the eye can feparate that intimate 
connection which certainly takes place be- 
tween the capfule of the vitreous humour 
and that of the crystalline lens : By pref- 
fure they are frequently both forced out; 
but no operator would wifh to meet with 
D 2 this, 



44 Difeafesof the Eyes. Ch. XXVII. 

this, and no perfon guards more effectual- 
ly againft it than Mr Pellier, infomuch, 
that the efcape of the vitreous humour, or 
even of any part of it, is an occurrence he 
rarely meets with. In fome cafes indeed 
Mr PelliiT infinuates his curette, as we 
have already remarked, through the pupil, 
with a view to detach the capfule of the 
lens from the contiguous parts : He allows 
however that this is not always necefTary; 
and befides, there is much caufe to fufpect 
that the eye would often be hurt by it. 

3. When it is found, as we have already 
obferved, either during the operation of 
extracting the cataract, or afterwards, that 
the capfule of the lens is opake, even Mr 
Pellier himfelf does not attempt to extract 
it by prefTure. In this cafe he does it with 
forceps pined through the pupil. Now, if 
prefTure anfwers in one variety of the dif- 
eafe, it ought probably to do fo in others, 
fo that the ufe of forceps fhould not be 
necefTary ; but it is only in the hydatid or 
foft cataract which Mr Pellier allows that 
this practice by prefTure fucceeds. 

4. But 



Sed. XIX. Difcafis of the Eyes. 45* 

4. But as feveral practitioners, both here 
-and elfewhere, have feen Mr Pellier extract 
the cataract, furrounded, as they imagi- 
ned, with its proper capfule ; and as he af- 
ferts with confidence, that it may be done 
merely bypreffure; it will be afked, In what 
manner is this apparent contradiction to be 
explained ? I can account for it only on the 
fuppolition of there being in all fuch cafes, 
where this practice of extracting the cap- 
fule entire is confidered as admiflible, a 
preternatural formation of a new mem- 
brane within the capfule of the lens j which 
being of a firmer nature than the capfule 
itfelf, and probably very little, if at all, at- 
tached to the contiguous parts, we can ea- 
fily fee how it may be forced out entire, 
even by moderate preffure, and how eafily 
byftanders may be deceived with it. When 
I firft faw it done by Mr Pellier, as I had 
previoufly been informed that the whole 
capfule would be extracted along with the 
lens ; as I had heard from very refpectable 
authority that he had done it in different 
inftances at Glafgow ; and as I certainly 
D 3 faw 



46 Difeafes of the Eyes, Ch. XXVIT. 

faw the cryftalline pufhed out, furround- 
cd with a membranous bag, I muft own 
that I was nearly converted to Mr Pellier's 
opinion : But on further confideration, 
the reafons I have mentioned agamft it 
appeared too conchifiv", even for this 
■weight of evidence to remove ; and (ince 
that period, a circumftance has occurred, 
which with me puts the matter beyond a 
doubt. A cataract of a foft nature was 
extracted by Mr Pellier, furrounded with 
this membrane or bag quite entire. From 
the firft I doubted much of its being the 
proper capfule of the lens, as it was faid to 
be : for this tunic is well known to be ex- 
ceedingly fine and delicate ; whereas this 
was a membrane of a tolerable degree of 
firmnefs, which required fome force to tear 
it. The patient, however, diflinguifhed 
objects immediately after the operation ; 
and what was then advanced concerning 
it could not be well refuted : But by fbme 
caufe or other, pofhbly from the eye be- 
coming inflamed, an opacity foon began 
to form in the ojd fite of the cryftalline 

directly 



Sea. XIX* Difenfes of the Eyes. 47 

directly behind the pupil, forming to all 
appearance, a real cataract ; and it now 
continues even after the inflammation is 
removed. Whatever explanation may be 
given of this by thofe who are inclined to 
fupport the contrary opinion, it proves to 
me a convincing proof, that fome decep- 
tion takes place in thofe cafes where it is 
fuppofed the capfule is extra&ed entire 
along with the lens ; for in this cafe, where 
the capfule was imagined to be taken en- 
tirely out, the opacity which fucceeded, 
and which ftill exifts, appears evidently to 
be feated in the capfule, and no where elfe. 
I therefore conclude, where practitioners 
have imagined the capfule has been extract- 
ed entire, that they have been deceived 
by the lens being enveloped with a preter- 
natural bag or cyft, formed perhaps by 
an inflammatory exfudation from the in- 
ternal furface of the capfule : That this 
production however is always formed in 
this manner, I will not pofiiively aflert ; 
but in my opinion it is the mod probable 
way by which we can account for it. 

D4 la 



4 8 Difeafcs of the Eyes. Ch. XXVII. 

In this variety of cataract, however, it 
is certainly right to attempt the extraction 
of this membrane, for virion will not be 
perfect while it continues in the eye. But 
if I may venture to diffent from the opi- 
nion of one fo verfant in matters of this 
kind as Mr Pellier is, I would obferve, 
that we fhould not, even in the mod fluid 
cataract, endeavour to extract it without 
opening the capfule fo as to difcharge the 
contents of it : for as the cyft of which 
we have been fpeaking does not appear to 
be firmly attached to the neighbouring 
parts, it is probable it would be feparated 
from them with as much eafe when quite 
empty as when perfectly full, and it would 
in this ftate pafs through the pupil with 
much lefs rifk of hurting the iris ; an ob- 
je(t which we have elfewhere endeavoured 
to mow is perhaps the rnofl important of 
any in this operation. 

Thefe are the remarks I have to offer on 
Mr Pellier's theory and practice in the ca- 
taract. If farther obfervation fhall con- 
vince ine that I am wrong, I will, readily 

acknow- 



Sea. XIX. Difeafes of the Eyes. 49 

acknowledge my miftake j but in the mean 
time the reafons I have adduced appear to 
evince the impropriety of extracting the 
capfule piecemeal by means of forceps 
paffed through the pupil, as well as the 
impombility of making it pafs entire along 
with the lens. 

Mr Pellier's practice, as we have already 
obferved, is not confined to the treatment 
of the cataract He is equally accuftomed 
to the management of every other difeafe to 
which the eyes are liable. In all of them 
he has acquired much ufeful experience ; 
but we fhall confine our account of his 
practice to thofe points in which his improve- 
ments appear to be of mod importance. 

In the treatment of ophthalmia or in- 
flammation of the eyes, whatever may be 
the caufe of the difeafe, he condemns the 
ufe of emollients, and trufts entirely to re- 
medies of an oppofite nature. When the 
inflammation is violent, is of long dura- 
tion, and does not yield to the ufual means 
employed for it, he recommends a free di- 
vifion of the turgid veflels on the adnata ; 

and 



5© Difeafes of the Eyes. Ch. XXVII. 

and in order to do the operation effectual- 
ly, he carries an incifion round the whole 
globe of the eye, on that part of it where 
it appears to be moft inflamed. The cur- 
ved fharp-pointed knife, Plate XLI. fig. 5. 
he recommends as the beft inftrument for 
this operation. But with thofe not much 
accuftomed to it, I believe it will be eafier 
done with the knife delineated in Plate 
XXXT. fig. 3. Vol. 111. * 

The fcari fixations being completed, the 
eye mould be immediately bathed in warm 
milk and water, in order to promote as 
much as poflible a free difcharge of blood: 
and this being done, he advifes a little of 
the following ointment to be introduced 
on the end of a blunt probe between the 
eye-lids, to be repeated once or twice 
daily as long as the difeafe may continue, 
at the fame time that a weak faturnine fo- 
liation 

* I wag clearly of this opinion when the firft edi- 
tion of this volume went to the prefs in the month of 
February laft ; but having of late made trial of Mr Pel- 
lier's inftrument in feveral cafes, I muft do him the 
juftice of acknowledging that it anfwers better than any 
•ther I have ever ufed. 



.PI, ATI, XIII 




|"H,\ II j 2. i 




Sea. XIX: Difeofes of the Eyes. 5* 

lution is employed morning and evening 
as a wafti. 

$. Mercur. precip rubr. 

Lapid. calamin. pp". aa 3ifs. 

Lythargyrii pp". - 3i. 

Tutiae pp". - 3fs. # 

Cinnab. nativ. - 9i. 

F. pulv. tenuiflim. et mifce cum axungiae 
porcinae §ii. et adde balfam. Peruviani 
gutt. xv. 

This ointment Mr Pellier makes ufe of 
with much freedom and advantage in all 
difeafes of the eyes that have cither been 
induced by inflammation, or that happen 
to be attended with it ; and he finds it par- 
ticularly ufeful in thofe cafes of Albugo or 
Leucoma where corrolive applications are 
admiflible. 

It fometimes happens in the fmall-pox, 
as well as in fevere inflammatory affec- 
tions of the eye, from whatever caufe they 
may originate, that the centre of the cor- 
nea is left in a ftate of opacity, by matter 
forming between the coats of it. When 
this is not carried off by the remedies 
ufually employed, if the iris, retina, and 

other 



5 4 DifeafcsofthcEy.es. Ch.XXVIL 

other parts of the eye appear to be found, 
Mr Pellier advifes an operation, from which 
he has in different inftances derived much 
advantage. The centre of the cornea be- 
ing opake, the rays of light are thus pre- 
vented from pamng to the bottom of the 
eye through the pupil ; but when the fides 
or external border of the tranfparent cor- 
nea ftill remain clear and found, light 
may be allowed to pafs to the retina by- 
enlarging the pupil ; which, Mr Pellier 
fays, may be done with fafety by making 
an incifion from one fide of the iris to the 
other. And his method of doing it is this: 
He firft makes an incifion in the promi- 
nent part of the cornea, in the fame man- 
ner as for extracting the cataract : He then 
inferts a fmall grooved director beneath 
the flap of the cornea through the pupil j 
and having paffed it in a horizontal direc- 
tion immediately behind the iris towards 
the outer angle of the eye, he now takes a 
pair of fmall curvid fcitfars, and pafling 
one of their blades along the groove of the 
director, he at once divides this part of the 
iris, when he withdraws the inftruments 

and 



Se^ XIX. Difeafes of the Eyes. 53 

and makes a fimilar incifion on the op- 
pofite fide of the eye. By this means, when 
the opacity is confined to the centre of the 
cornea, which is frequently the cafe, the 
rays of light which pafs through the fides 
of it will now get accefs to the bottom of 
the eye, by the pupil being extended from 
one fide of the iris to the other : and thus 
a degree of vifion will be produced which 
could not otherwife be obtained. It will 
readily be imagined that perfect vifion is 
not to be expected in this ftate of the eye; 
for a variety of reafons concur againft it : 
but it is a matter of much importance for 
a perfon already totally blind to be render- 
ed capable of finding his way, and of con- 
ducting himfelf from one place to another, 
which by this operation Mr Pellier has 
done in different inftances : and, fo far as 
I know, the public are indebted to him 
alone for propofing it. 

After the operation, the eye muft be 
tied up, and treated in the fame manner 
and with the fame attention as is done 
after the extraction of the cataract ; for 

where 



54 Difeafes of the Eyes. Ch. XXVII. 

■where fo much violence is done to the eye, 
if inflammation be not guarded againft, 
much mifchief may occur from it. 

In defcribing the method of dividing 
the iris, we have faid that it fhould be 
done with the fcifTars ; for this membrane 
being loofe and unfupported, it would 
yield before the edge of the fharpeft knife. 
In the introduction of the director and 
fcifTars, care fhould be taken, in palling 
them between the iris and lens, not to in- 
jure either the lens or its capfule ; that is 
when the difeafe is not complicated with a 
cataract ; for when the cryflalline is opake 
it fhould be extracted. 

In the treatment of the fiftulalachrymalis, 
Mr Pellier has much merit ; for, with moft 
operators, it feldom happens that any per- 
manent advantage is obtained from any of 
the remedies employed in it, and even they 
who are much accuflomed to the manage- 
ment of it often fail entirely. Mr Pellier 
does not fay that he always fucceeds ; but 
he does fo in moft inftances ; and I know 
that his method has often proved fiiccefsful 
where others have failed. 

In 



Sect. XIX. Difeafes of the Eyes. $5 

In a confirmed fiftula lachrymalis, the 
curative intention is, to form an opening 
between the lachrymal fac and the cor- 
refponding noftril. There are different 
methods of effecting this : — By fearching 
with a blunt probe, to difcover the natu- 
ral paffage : if this fails, by making an 
artificial opening through the os unguis : 
and when neither of thefe fucceed, by lea- 
ving a tube or canula, either in the natu- 
ral or artificial opening, for the purpofe of 
conducting the tears to the nofe. 

As we know from experience, that the 
operation fails in various inftances, from 
the paffage becoming again impervious, 
and this whether it may have been done 
by opening the natural paffage or by form- 
ing another, it would be the idea perhaps 
of moft practitioners to leave a tube in the 
opening, were it not liable to one very ma- 
terial objection, namely, the uncertainty 
of its continuing fixed in its fituation : for 
hitherto we have not been poffeffed of any 
certain method of preventing the canula 
either from rifing and forcing its way out 

at 



$6 Difeafes of the Eyes. Ch. XXVII. 

at the corner of the eye, or from paffing 
down and coming out at the nofe. In 
Plate XXXVII. Vol. III. I have already 
delineated various forms of tubes which 
have been ufed for this purpole ; and of 
thefe, figures 3. and 10. will in moft cafes, 
I believe, be found to anfwer : for when 
they are prefTed fufficiently into the open- 
ing through the os unguis, the bulge or 
prominence with which they are furnifhed 
above, will for the moft part prevent them 
from riling, while their conical fhape will 
prevent them from paffing into the nofe. 
I mull, however, acknowledge, that they 
fometimes fail ; and that an invention of 
Mr Pellier's appears to be much fuperior 
to them. I know one inflance in which 
it has hitherto anfwered completely, 
and eight months have elapfed fince the 
operation *. From the form of the tube, 
there is much reafon to imagine it 
will anfwer ; and Mr Pellier aflerts, that 

when 

* It is now, when this fecond edition is going to the 
prefs, eighteen months fince this operation was per- 
formed : The tube ftill continues fixed in its fituation ; 
it is not productive of any kind of uneafinefs ; and the 
cure is complete. 



1 



I'l^Y-TK/XUL. 







Se&. XIX. Difeafes of the Eyes. 57 

when it is properly introduced it never fails. 
Two reprefentations of it are given in Plate 
XLII. figures 5 and 6. It may be made 
either of gold or lead. Mr Pellier com- 
monly employs lead : but when made of 
gold, the tube will not be fo bulky if o£ 
the fame ftrength ; and as this metal re- 
ceives a finer polifh, by which the open- 
ing through it will not fo readily fill up 
with the tears, it ought, I think, to be pre* 
ferred. 

The peculiarity of form of Mr Pellier's 
tubes confifts in their having two project- 
ing edges j one at the top forming a kind 
of brim, correfponding as nearly as po£- 
fible to the fize of the lachrymal fac ; and 
the other near to the middle between this 
and the other end of the instrument ; by 
which means, when it is properly fixed in 
the palTage where it is to remain, it is kept 
firm in its fituation by the granulations 
which fhoot out from the contiguous parts; 
and which, by grafping as it were thaC 
part of the tube which lies between the two 
edges, effectually prevent it from pa (Ting 

Vol. IV. E either 



58 Difeafes of the Eyes. Ch. XXVII. 

either upwards or downwards ; and hence 
that material inconvenience is avoided 
which practitioners who employ cylindri- 
cal tubes always complain of. 

It is neceffary, however, to obferve, that 
the utmoft nicety is required in the ufe 
either of thefe or indeed of any other tubes j 
in the firft place, in adapting them with 
exactnefs to the fize of the openings thro' 
which they are to pafs ; and afterwards in 
the introducing them a proper length into 
the nofe : For if a cube be either too fmall 
or too large for the opening through the 
os unguis, we m?y readily imagine that it 
will not anfwer ; and if it be prefled even 
a very little too far into the noflril, it will 
neceffarily irritate the lining membrane of 
that cavity fo as to create much pain and 
inconvenience. The tubes reprefented in 
Plate XLII. are of a fize both in length and 
thicknefs which anfwer for the molt part 
of adulrs, but practitioners mould be pro- 
vided with them of various fizes. 

The method of ufing them is this. After 
laying the lachrymal fac freely open in the 

ufual 



Sect. XIX. Difeafes of the Eyes. $9 

ufual way, the natural conduit of the tears 
is fearched for, either with a firm probe, 
or with the conductor, Plate XLII. fig. 2. ; 
and Mr Pellier afTerts that he never fails in 
finding it. As foon as this is difcovered, 
the tube muft be put upon the conductor, 
previoufly furnifhed with the comprefTor, 
fig. 3. as in fig. 4. ; and it fhould be of 
fuch a fize that the conductor may fit it 
exactly in point of thicknefs, while the 
end of this inflrument is fo much longer 
as to pafs through it about the tenth pare 
of an inch. The point of the conductor 
is now to be infinuated into the lachry- 
mal duct ; and being pufhed in till it 
reaches the noftril, which may be known 
either by inferting a probe into it, or by a 
few drops of blood being obferved to fall 
from the nofe, the conductor being no long- 
er necefTary, muft be withdrawn, taking care 
to leave the comprefTor upon the upper 
brim or edge of the canula ; which muft 
be firmly prefTed down with it in the 
left hand, while the conductor is removed, 
with the other. If this precaution be not 
attended to, the canula would, be brought 
£ 2 out 



60 Difeafes of the Eyes. Ch. XXVIL 

out along with the conductor ; but thi* 
inconvenience is in this manner very ef- 
fectually prevented, while the fame inftru- 
ment ferves more eafily than any other to 
prefs the canula to a fufficient depth in the 
lachrymal duct : a point of the firft im- 
portance in the performing of this opera- 
tion ; for if the canula be not fixed with 
fome degree of firmnefs even at the firft 
attempt, there will afterwards be more 
pain and difficulty in doing it. 

This being done, the compreflbr muft 
,next be taken out ; and, with a view to 
difcover whether the canula is at a pro- 
per depth or not, a little milk and wa- 
ter fhould be injected through it with 
the fyringe, Plate XXXVII. fig. I. If the 
injection pafles freely and eafily into the 
noflril, while the upper part of the canula 
is prefTed down to the middle of 'the la- 
chrymal fac, there will be no reafon to 
doubt of its being properly' placed : l£ y on 
the contrary, any obflruction occurs, there 
will be reafon to fufpect that it is already 
pufhed too far, and that it prefTes againft 
the os fpongiofum inferius j in which cafe 

the 



Sea. XIX. Difeafes of the Eyes. 6 1 

the canula fhould be withdrawn, with a 
view to fhorten it, when it muft be again 
introduced in the manner we nave men- 
tioned. 

As the wound recently made in the fac 
will yield a confiderable quantity of mat- 
ter, it is necelTary to preferve it open for 
eight or ten days with a bit of foft lint 
fpread with any emollient ointment, taking 
care to cover the whole with a comprefs of 
foft old linen, fecured with a proper ban- 
dage. An injection of milk and water 
fhould be daily paffed through the canula ; 
and at the end of this time, or whenever 
the fuppuration is much diminifhed, and 
the fore looking clean and healthy, the 
dofTil of; lint muft be entirely removed ; 
and a piece of court-plafter being laid 
over the fore, it may in this ft ate be left 
to heal, care being taken to renew the pla- 
fter if any matter appears to form beneath 
it. 

Ey this mode of treatment, cafes of -fi- 
ftula lachrymalis, that do not depend up- 
on difeafed contiguous bones, or any la- 
tent difeafe of the con ft i tut ion, will for the 
E 3 moft 



62 Difeafes of the Eyes. Ch. XXVIfc 

moft part, as Mr Pellier obferves, be com- 
pletely cured in three weeks, nay fometimes 
in a fortnight, which by the ufual practice 
might require three, four, or five months. 

As I have been witnefs of the moft 
complete fuccefs of Mr Pellier's prac- 
tice in this difeafe, I have confidered it as 
a point of juftice, not only to Mr Pellier 
but to the Public, to give this full detail 
of it. Indeed, if I had not been convin- 
ced of the fuperior utility of Mr Pellier's 
practice, and of the unreferved manner in 
which he communicated his knowledge of 
the difeafes of the eyes, I fhould have deem- 
ed it impertinent to have given the prece- 
ding account of either to the Public. 

Since the firfl edition of this volume was 
publifhed, the opinion which I then fug- 
gefled, of the impombility of extracting the 
capfule of the lens entire, has been the fub- 
je<5l of much inveftigation : And as it now 
appears that it cannot be done, I ftill con- 
clude, that Mr Pellier, and others who adopt- 
ed a different opinion, have been deceived. 

CHAP. 



Seel. I. Difeafes of the Nofe 6$ 



CHAPTER XXVIII. 



Of the Diseases of the Nose and Fauces. 



SECTION I. 



Anatomical Defcription of the Nose and Fauces. 



A Minute defcription of thefe parts is 
not necefTary for our purpofe ; but 
a few remarks upon their general form and 
ftructure may ferve in fome meafure to 
elucidate the nature of thofe difeafes to 
which they are liable. 

The external prominent part of the nofe 
is chiefly compofed of bones and cartila- 
E4 ges, 



64 Difeafes of the Ch. XXVIII. 

ges, which ferve to protect the more deep- 
feated parts of the organ of fmell, and to 
form a kind of vaulted paflage for the air 
to the throat. 

This paffage, divided by the feptum nafi, 
forms the noftrils, which extend almoft in 
a horizontal direction from the fuperidr 
part of the upper lip backwards to the 
pharynx, where they terminate above the 
velum pendulum palati. 

The fuperior and lateral parts of the 
arch of the nofe are formed by the nafal 
procefs of the os frontis, — by the two ofla 
nafi, — by the ofla unguis, — and by an ex- 
tenfive procefs from each of the ofla ma- 
xillaria, to which the cartilaginous alse of 
the nofe, covered by the common tegu- 
ments, are immediately attached. 

The feptum narium is formed by the 
nafal procefs of the ethmoid bone,— by 
the vomer, — by the middle cartilage of the 
nofe, — and by the fpinous procefles of the 
palate and maxillary bones. 

The under part of the cavity of the 
nofe is anteriorly bounded by a horizon- 
tal 



Sett. I. Nofe and Fauces, 6$ 

tal procefs of the ofla maxillaria, and 
backwards by a procefs of a fimilar form, 
from each of the ofTa palati. The fphenoid 
and ethmoid bones form the boundaries 
of the pofterior part of the nares. 

Towards the upper part of the nofe, we 
meet with a very beautiful contrivance of 
nature for enlarging the organ of fmell. 
In the fuperior part of each noftril, oppo- 
fite to the feptum, we find a fpongy, cellu- 
lar production of bone, proceeding from 
the os ethmoides, which, from their form, 
texture, and fituation, are termed Conchae, 
Ofla Spongiofa, or Ofla Turbinata Supe- 
riora : And beneath tbefe, on the fame 
fide of the noflrils, are two bodies of a fi- 
milar texture, which have likewife been 
fuppofed to be productions of the ethmoid 
bone, but of which there is no evidence. 
Thefe, from their fituation, are termed Of- 
fa Spongiofa Inferiora. Jn fome inflances, 
two, and even three, fmall bones of this 
kind have been met with in each noftril ; 
but this is not a frequent occurrence. 

Thefe bodies being prominent, and even 

fome- 



$6 Difeafet of the Ch. XXVIII. 

fomewhat irregular on their furfaces, give 
the noftrils a winding, or even a crooked 
appearance : but every practitioner will 
know that they are fo in appearance only; 
infomuch that a common probe may be 
paffed almoft in a ftraight line from the 
external nares to the throat. 

We meet with feveral openings which 
terminate in the noftrils, fome of which it 
is material for furgeons to be acquainted 
with ; viz. The ductus inciforii, which 
commence at the under and back part of 
the noftrils, and terminate behind the den- 
tes incifivi of the upper jaw ; — the finufes 
of the fphenoid and frontal bones, which 
both open into the upper part of the na- 
res ; — the finus of each maxillary bone, 
commonly termed the Antrum MaxilJare, 
or Highmorianum, which opens into the 
nofe between the upper and under ofTa 
fpongiofa of the fame fide ; — and laftly, 
the duds of the lachrymal facs, which we 
have formerly had occafion to defcribe, 
and which terminate on each fide imme- 
diately 



Sect. I. Nofe and Fauces. 6f 

diately beneath the os fpongiofum infe- 
rius. 

All the cavity of the noftrils ; the differ- 
ent finufes we have mentioned, as well as 
the pafTages leading to them ; the whole 
furfaces of the ofTa fpongiofa, and even the 
fauces, are covered or lined with a thick, 
foft membrane, which, from its affording 
a plentiful fecretion of mucus, is com- 
monly termed Membrana Pituitaria, or 
Membrana Schneideri, from Schneider, 
the firft anatomift who gave an accurate 
defcription of it. 

This membrane appears to be a continu- 
ation of the cuticle. Towards the external 
nares, near to its connection with the epi- 
dermis, it is exceedingly thin; but as it 
proceeds backward upon the feptum nafi 
and on the offa fpongiofa, it acquires a con- 
fiderable degree of thicknefs ; and again 
becomes thin as it proceeds to line the dif- 
ferent finufes. 

The cavity of the nofe, as we have al- 
ready remarked, is feparated from the 
mouth by a plate of bone, formed by a 

procefs 



£3 Difeafes of the Ch. XXVIII. 

procefs from each of the ofTa maxillaria, 
and by the ofTa palati. To the pofterior 
edge of the laft-mentioned bone there is a 
firm membrane connected, termed the Ve- 
lum or Valvula Palati, formed by a junc- 
tion of the common membrane of the 
mouth, with a continuation of the Mem- 
brana Schneideri, together with feveral 
mufcular fafciculi, intended for the motion 
of this and the contiguous parts. This 
membrane, as it ftretches back from the 
palate, falls down and terminates in the 
uvula immediately above the root of the 
tongue ; by which it is not only well fitted 
for preventing the food, during maftication 
and deglutition, from palling up to the 
nofe, but for conveying backwards to the 
pharynx all fuch parts of the mucus fur- 
nifhed by the membrane of the nofe and 
contiguous finufes as are not difcharged 
by the external nares. 

On each fide of the throat, at the termi- 
nation of the velum pendulum palati, there 
is fituated a prominent glandular fub- 
ftance commonly termed the Amygdala 

or 



Sect. I. Nofe and Fauces. 69 

or Almonds of the Ear. They are natu- 
rally of a fofc, yielding texture ; and in 
general they have excavations of different 
degrees of deepnefs on various parts of 
them, which, by thofe not acquainted 
with the ufual appearance of thefe parts, 
are often miftaken for ulcerations. On 
looking farther into the throat, along the 
courfe of the tongue, a thin, elaflic, carti- 
laginous body is obferved, termed Epi- 
glottis, which is fo placed as to prevent 
the food from falling into the trachea in 
its pafTage from the mouth to the pharynx, 
a wide capacious bag, which terminates 
in the cefophagus, and occupies all that 
part of the throat which is feen on looking 
into the mouth. 

From this defcription it is evident, that 
the pharynx is furnifhed with feveral o- 
penings or outlets. Below, it terminates 
in the cefophagus ; — anteriorly, it com* 
municates directly with the mouth j — and 
from the fuperior part of the bag it has a. 
free direct: communication with the pofte- 
rior openings of the noflFils. 



7 o Difeafes of the Ch. XXVIII. 

We fhall now proceed to confider the 
difeafes of the parts which we have defcri- 
bed, and the operations which are pracli- 
fed in the treatment of them. The fub- 
jects to be treated of are, — Hemorrhagies 
from the Noftrils — Ozasna — Imperforated 
Noftrils — Polypous ExcrefcencesintheNofe 
and Throat — Extirpation of the Amygdalse 
and Uvula — and Scarifying and Foment- 
ing the Throat. 



SECTION II. 

i 
Of Hemorrhagies from the Nostrils. 

r jPHE internal parts of the.nofe are fup- 
plied almoft entirely with blood from 
the internal maxillary artery : And, in ge- 
neral, the branches of this artery which 
go to the nofe are fo extremely fmall, as to 
render a diviflon or rupture of any of them 
an obje& of little importance. In fome 
inftances, however, the rcverfe of this 

takes 



Sect. I. Nofe and Fauces. 71 

takes place, and hemorrhagies occur from 
thefe parts which prove highly embar- 
rafling to practjtioners, and very hazar- 
dous to patients. They have fometimes 
even baffled every attempt that could be 
made to reftrain them. However trifling, 
therefore, this evacuation may for the mod 
part appear, it ought always to be treated 
with attention. 

In a great proportion of cafes, a proper 
application of cold puts a temporary ftop- 
page to the difcharge ; and in general, 
any future returns of it may be prevented 
by blood-letting, by a moderate ufe of 
cooling laxatives, and a low regimen. 

In order to obtain all the advantages 
that may be derived from the application 
of cold, it muft be employed in various 
ways, and to a confiderab'e extent. The 
patient fhould be placed in a large apart- 
ment, with a current of cold air palling 
through it : His food and drink ought all 
to be cold : His face fhould be frequently 
bathed, and even immerfed, in cold water, 
or in cold water with a proportion of vine- 
gar: 



72 Difeafes of the Ch. XXVIII. 

gar : A ftrong folution of alum, or of any- 
other aftringent, mould be ufed from time 
to time as a gargle : Comp/elTes wet in any 
liquid of this kind mould be applied over 
the nofe: When in bed, he mould be very 
lightly covered ; and he mould fleep with 
his head as high as poflible. 

By thefe means duly perfifted in, na- 
fal hemorrhagies may in general be re- 
moved ; but in fome inftances no advan- 
tage whatever is derived from them, and 
the flow of blood is not in any degree di- 
minifhed by the molt exact application of 
them. 

In fuch cafes, compreffion of the ruptu- 
red blood-vefTel is alone to be depended 
on ; but when the part affected is deeply 
feated in the noftril, the application of 
preflure is both difficult, and uncertain. 
It will fometimes happen that a doflil of 
lint introduced into the bleeding noftril 
will put an immediate ftop to the dif- 
charge. This, however, is a rare occur- 
rence ; for the extent and diameter of the 
paflage through which the doffil muft be 

pufhed 



Sect. II. Nofe and Fauces. 73 

pufhed being very unequal, the effect pro- 
duced by it muft likewiie be fo : From this 
circumftance, we cannot place much de- 
pendence on this method of applying pref- 
fure. 

In a former part of this work, when 
treating of evacuations of blood from the 
anus in cafes of piles, we advifed the ap- 
plication of preflure, by the introduction 
of a piece of gut, tied at one end, into the 
rectum, and by filling it at the oppofite 
extremity with any cold liquid, to increafe 
the degree of preffure by forcing up the li- 
quid and fecuring it with a ligature. The 
fame remedy may be employed in hemor- 
rhagies from the nofe. It has already been 
fuccefsfully made ufe of in a few inftan- 
ces ; and may frequently, we think, be 
employed with advantage. A piece of 
hog's gut, that has been previoufly dried 
and moiftened again, anfwers beft. One 
end of it firmly tied with a bit of fmall 
packthread, mould, by means of a probe or 
director, be puihed along the whole courfe 
of the noftril from which the blood is dif- 

Vol. IV. F ' charged, 



74 Difeafes of the Ch. XXVIII. 

charged, to the upper end of the pharynx. 
The gut mould now be filled with cold vi- 
negar, water, or any other cold liquid, 
by means of a fyringe inferted at the end 
hanging out at the noftril ; and as much 
being injected as the gut will admit, the 
whole fhould be prefTed as far up as pot- 
fible, and mould be fecured in this fitua- 
tion bv a firm ligature. 

In this manner a very confiderable degree 
of preffure may be applied ; and fome ad- 
vantage may be derived from the applica- 
tion of cold directly to the vefTel from 
whence the blood is difcharged. In fome 
inflances, however, even this may be 
found to fail, owing to the ruptured vef- 
fel being fo fituated that preffure cannot 
in this manner be applied to it. In fuch 
circumftances, we muft attempt by other 
means to put a Mop to the hemorrhagy • and 
it may commonly be done in the follow- 
ing manner. 

Let the curved inftrument, fig. 4. Plate 
XLIII. be inferted at one of the noftrils 
with a piece of catgut or firm waxed thread 

con- 



[ L.ATG \l,lll 




Sect. II. Nofe and Fauces, 75 

contained in it ; and being conveyed into 
the throat, the ligature rauft be laid hold 
of with a pair of forceps, and taken out at 
the mouth, when the inftrument is to be 
withdrawn and again introduced at the 
other noftril with a ligature of the fame 
kind. A bolder of foft lint, of a fufficienc 
fize for duffing or filling up the pofterior 
nares is now to be firmly tied to the two 
ends of the ligatures hanging out at the 
mouth when the oppofite ends of them 
muft be pulled forward at the noflrils till 
the cuftiion of lint is firmly applied to and 
fixed in the upper part of the pharynx ; 
when a comprefs of lint muft be applied 
to each noftril, and fixed in this fituation 
by tying the two ligatures over it. The 
patient fhould now be laid to reft. If the 
bolfters of lint have been properly applied, 
no blood will efcape either from the pofte- 
rior or anterior nares ; any blood that is 
eifufed into the noftrils will foon coagu- 
late, and thus a flop will be put to the he- 
morrhagy. It is evident, however, that in 
order to infure fuccefs to this operation, 
F 2 the 



7 6 Difeafes of the Ch. XXVIII. 

the bottlers of lint fhould not only be ap- 
plied with much exacmefs, but ought to 
be continued for a length of time fuffi- 
cient for admitting of the healing or re- 
union of the ruptured blood-vefTels. 

In fixing the bolfter of lint in the back 
part of the mouth, we have advifed two 
ligatures to be employed ; one to be paffed 
through each noflril. In this manner it 
may be applied not only more firmly, but 
more equally, than by the ufual method of 
only one ligature paffed through that no- 
ftril from whence the blood is difcharged. 

SECTION III. 

Of an Oz^ena. 

'T'HE term Ozsena has in general been 
applied to fuch ulcers of the nofe as 
are foul, that difcharge a fetid matter, and 
that are attended with a carious flate of 
one or more of the bones; whilft by fome 
the fame general denomination of ozaena 
is applied to every ulcer in the noftrils, 

whether 



Se<5l. III. Nofe and Fauces. 77 

whether attended with a caries or not. — At 
prefent we fhall adhere to this laft accep- 
tation of the term. 

Every catarrh affecting the lining mem- 
brane of the' nofe, is attended in a greater 
or lefTer degree with an inflamed ftate of 
the parts immediately difeafed. But we 
know, that in general this terminates ea- 
rn , and that the inflammation is remo- 
ved by a plentiful difcharge either of mu- 
cus or of a thick yellow matter. In fome 
inftances, however, even after every other 
catarrhal fymptom is removed, this dis- 
charge of matter continues obftinate, either 
from ulceration alone, or perhaps from 
ulceration conjoined with fulnefs and fwell- 
ing of the lining membrane of the nofe. 

Expofure to cold is to be considered as 
the mod frequent caufe of this ftate of the 
difeafe.; but external violence of every 
kind that terminates in an inflamed ftate 
of the membrane of the nofe, fuch as the 
application of acrid irritating fubftances, 
blows and bruifes, &c. may likewife be 
productive of it. 

F 3 W hen 



7 8 Difcafes of the Ch. XXVIIT. 

When the fyftem is not affected with 
any other difeafe, this is the-rnoft fimple 
variety of an ozaena ; and as in this flate 
we fuppofe the affection to be perfectly 
local, local remedies ought alone to be re- 
commended. 

In this Pcate of the difeafe, applications 
of a moderately drying and aftringent na- 
ture are chiefly to be depended on. Of 
thefe, decoctions of walnut-tree leaves, 
of Peruvian or oak bark, mixed with a fo- 
lution of alum, and all the faturnine folu- 
tions, are perhaps equal if not preferable to 
any. Brandy or any other ardent fpirits 
diluted with water, and lime-water, may 
likewife be employed with advantage. 

Doffils of foft lint foaked in any of thefe 
fhpuld be introduced into the affected no- 
ftril three or four times daily, and mould 
be pufhed up as far as may be neceiTary 
for coming into contact with the affected 
parts : and every night at bed-time an 
ointment fhould be applied, prepared with 
a confiderable proportion of calcined zinc 
or of lapis calaminaris. 

By 



Sect. III. Nofe and Fauces. 79 

By a due continuation of thtfe means, 
every local affection depending on ulcera- 
tion of the membrane of the nofc will be 
at laft removed. But inftances have oc- 
curred of other difeafes being mistaken for 
fores in the nofe, and of the running pro- 
duced by them continuing to refill every 
effort that could be made for its removal. 
This is particularly the cafe with collections 
of matter in the antrum maxillare. 

In the anatomical defcription we have 
given of thefe parts, we have {een i that 
there is naturally a paffage or opening 
from the antrum maxillare into the nofe 
immediately below and covered by the os 
fpongiofum inferius of the fame fide. In 
collections of matter in this cavity, wmen 
in confiderabie quantity, it is occasionally 
difcharged by this outlet into the nofe in 
every poflure of the body, and almoft al- 
ways when the patient lies on the found 
or oppofite fide, if the pafTage be not ob- 
structed. The method of treatment befl 
fuited for the removal of collections in the 
antrum maxillare will be the fubject of a 
F 4 • feet ion 



8o Difeafes of the Ch. XXVIII. 

fection in the enfuing chapter : At prefent 
we have only to fay, that in the treatment 
of difeafes attended with a difcharge of 
matter from the nofe, practitioners ought 
to be on their guard, left, by mi flaking one 
difeafe for another, mifchief may be done ; 
not only by a mifapplication of remedies, 
but by thofe means being omitted from 
whence alone any real advantage could be 
derived. 

When, again, the matter difcbarged from 
an ulcer in the nofe is thin, fetid, and of a 
brown or fomewhat black colour, as there 
wdl be much caufe to fufpect from this 
that the contiguous bones are carious, it 
will be in vain to expect a cure till thefe are 
removed. We may in general be certain 
of the exiftence of caries merely by the 
peculiar fetor of the matter which fuch 
fores afford ; but when any doubt remains 
of this, we have it commonly in our power 
to be determined with certainty by the in- 
troduction of a probe. 

As a carious flate of the bones of the 
nofe occurs more frequently as a fymptom 

of 



SeA.HI. Nofe and Fauces. Si 

of lues venerea, than from any other caufe, 
this ought to b° kept in view in every af- 
fection of this n imre : And whether we 
may be able to trace it with certainty as 
a fymptom of this difeafe or nor, whenever 
there is the leaft caufe for fufpiciou, the 
patient ought, without hefitation, to be put 
upon a long continued courfe of mercury. 
Indeed, from whatever caufe the dif )rder 
may arife, mercury will not probably do 
harm ; and as I have feen it prove fervice- 
able even where there was no caufe to fuf- 
pecT: a venereal taint, I now in general 
make it a rule, in all fuch cafes, to advife 
it immediately. 

In the mean time the local treatment of 
the fores fhould be particularly attended 
to. The parts fhould be bathed from 
time to time with one or other of the de- 
coctions already mentioned ; and as the 
foft fpongy bones of the nofe are apt, 
when carious, to produce troublefome fun- 
gous excrefcences, ointments, impregna- 
ted with corrofive applications, fhould be 
employed occafionally ; and of thefe there 

are 



Zt Difeafes of the Ch. XXVIII. 

are none I have ever tried that anfwer fo 
well as prepared verdegris or red precipi- 
tate. There is a general prejudice indeed 
againft the ufe of remedies of this kind in 
difeafes of the internal parts of the nofe, 
from a fear of their doing mifchief, by ir- 
ritating the very fenfible membrane to 
■which they are applied. There is no good 
caufe, however, for this timidity ; and I 
can fay from experience, that ointments, 
fuch as I have mentioned, of a ftrength 
fufficient for keeping down the moft part 
of fungous excrefcences, may be employ- 
ed with much fafety, and without any rifk 
of injuring the contiguous parts. It is 
fcarcely neceffary to remark, that in the 
ufe of remedies of this kind, fome pru- 
dence and attention is required to adapt 
the ftrength of them to the parts to which 
they are to be applied. The internal fur- 
face of the nofe will not bear the fame de- 
gree of irritation that may with fafety be 
applied to fome other parts of the body ; 
but it will bear the application of corrofive 
ointments more ftrongly impregnated than 

is 



Seft. HI. Nofe and Fauces. S$ 

is commonly imagined. A liniment com- 
pofed of wax and oil, with an eighth or 
ninth part of red precipitate, or a fmaller 
proportion of verdegris, may in general be 
employed with perfect fafety, and the cor- 
rofive powers of it can be occafionally in- 
creafed or diminifhed. The growth of 
fungous excrefcences being thus prevent- 
ed, and the fores being kept clean by the 
frequent ufe of an aftringent antifeptic 
warn, the pafTage of the noftril will be pre- 
ferved pervious, the diforder will not fpread 
fo readily, and at the fame time the difea- 
fed bones will probably be more quickly 
feparated and thrown off than when thefe 
circumftances are not duly attended to. 

Till the caries is removed, no perma- 
nent cure can be expected. The treatment 
therefore which we have juft recommend- 
ed mould be perfifted in till this is fully ac- 
complifhed. Indeed, after a fufficient quan- 
tity of mercury is exhibited for the remo- 
val of any latent venereal taint that might 
exift in the fyftem, all that we can expect 
farther from art, is to aftift in the manner 

we 



S 4 Difeafes of the Ch. XXVIII. 

we have advifed, in effecting a reparation 
of fuch bones as are difeafed. This being 
done, the fores will now be of a milder 
nature, and will in general heal by a con- 
tinuance of the aftringent applications we 
have already pointed out. 

This is the practice which by experience 
I have found to prove the moft fuccefsful 
in cafes of ozaena. It muft however be ac- 
knowledged, that no remedies with which 
we are acquainted can with certainty be 
depended on ; and ulcers of this kind 
prove conftantly extremely tedious, not only 
from the difficulty of reaching them with 
proper dreflings, but from the ofTa fpon- 
giofa, when they become carious, being 
always flow in exfoliating. When how- 
ever the fyftem is not otherwife difeafed, 
the means we have mentioned, being per- 
fevered in, will very commonly accomplifh 
our purpofe. 



SECT. 



Sed. IV. Nofe and Fauces. 85 

. SECTION IV. 

Of Imperforated Nostrils. 

/"^Hildren are not unfrequently born 
with the vagina or anus in an imper- 
forated ftate ; and although we know of 
no reafon why the noflrils mould not alfo 
be frequently imperforated, we are certain 
that it is a rare occurrence. Every practi- 
tioner, however, muft have met with fome 
inftances of preternatural adhefions of the 
noflrils, the confequence of confluent 
fmall-pox, of burns, or venereal fores. 

Obftructions of this kind are in various 
degrees. In fome cafes the noflrils are on- 
ly (lightly contracted, without producing 
any material impediment of the breathing. 
In others, they are fo much drawn toge- 
ther, as hardly to admit a common probe 
or a frnall quill : And in a few, the paflage 
is entirely oblirerated. 

In all fuch cafes it is the object of fur- 

gery 



85 Difcafes of the Ch. XXVIII. 

gery to remove every preternatural obftruc- 
tion ; but as any operation for this pur- 
pofe is productive both of pain and incon- 
venience, the amftance of art is not fre- 
quently delired. It ought undoubtedly, 
' however, to be employed whenever the 
breathing is much obftructed, or when the 
deformity produced by the difeafe is con- 
fiderable. 

When an opening is left in the obftruc- 
ted noftril, however fmall it may be, much 
amftance may be derived from it in effec- 
ting our intention. A fmall grooved di- 
rector being inferted into it, the paffage 
may be eaiily enlarged to its natural fize, 
by running a fmall biftoury or fcalpel into 
the groove in the courfe of the adhefion : 
But when there is no palTage whatever, 
whether the affection may be owing to a 
natural conformation, or to any other 
caufe, we mould, in the firft place, by 
flow direction with a fmall fcalpel, en- 
deavour to difcover one of the noftrils, ta- 
king care, with as much caution as pof- 
fible, to keep the opening in a proper direc- 
tion 



Secft. IV. Nofe and Fauces. Sj 

tion between the feptum and the contigu- 
ous external cartilage : And the pafTage 
being once difcovered, it mud be enlarged 
to the natural fize in the manner we have 
mentioned, by the introduction of a di- 
rector and biftoury. This being accom- 
plished in one noftril, we muft endeavour, 
by the fame kind of cautious difTe&ion, to 
difcover the other. 

A clear opening being thus formed into 
each noftril, our next object is to endea- 
vour to prefer ve them of a full fize, and to 
prevent adhefions from forming in any 
part of them ; which by experience we 
know are extremely apt to occur, and 
which can be prevented only by much at- 
tention. 

The introduction of dofhls of lint of an 
adequate fize, or of any other foft fub- 
ftance, and retaining them till there is no 
rifk of future adhefions, taking care how- 
ever to withdraw them daily for the pur- 
pofe of cleanfmg or renewing them, mighc 
no doubt anfwer our intention : but me- 
tallic tubes, adapted to the fize of the open- 
ings, 



88 Difeafes of the Ch. XXVIIL 

ings, at the fame time that they allow the 
patient to breathe with freedom through 
the noftrils, ferve to diftend the parts with 
more equality, and are more eafily retain- 
ed in their fituation. Before being intro- 
duced, they mould be covered with foft 
leather fpread with any emollient oint- 
ment ; by which they fit with more eafe, 
and will be more readily withdrawn at the 
different dreffmgs. 

Various forms of tubes have been re- 
commended for this purpofe. Thofe re- 
prefented in fig. 2. Plate XLIII. are of a 
form which will be found to anfwer per- 
haps equally well with any that have been 
propofed ; and they may be retained either 
with a bandage round ithe head, or with 
adhefive platters connected with them. 
They fhould be employed as long as any 
degree of forenefs or excoriation is percep- 
tible in the courfe of the incifions ; for if 
they are withdrawn before the fores are 
completely healed, new adhefions or con- 
tractions will very certainly enfue. 

It fometimes happens from burns, as 

well 



Sect. IV. Nofe and t Fauces. 89 

well as from the confluent fmall-pox, that 
along with a contraction, or perhaps a total 
obliteration, of one or both noftrils, an 
adh.efion is produced between the nofe ahd 
the fkin of the upper lip. In this cafe the 
adhefion of the lip to the nofe ihould, in 
the firft place, be feparated by flow difTec- 
tion with a fcalpel ; and the fore thus pro- 
duced mould be perfectly heal and firmly 
cicatrifed before any attempt is made to 
open the noftrils. It is fcarcely neceflary 
to remark, that, during the cure, the fore 
ihould not only be kept properly covered, 
but, with a view to remove any improper 
contraction which the lip may have acqui- 
red, it ought at each drefling to be tied down 
by feveral turns of a double-headed roller 
palled round and over the head. 



Vol. IV. G SECT. 



9* Difeafes of the Ch. XXVIII, 



SECTION V. 

Of Polypi in the Nose and Throat. 

r T^HE internal furface of the nofe is liable 
to excrefcences, which, from their 
form being fuppofed to refemble that of 
infects of this name, have commonly been 
termed Polypi. Every part of the nafal 
cavity, and of the back part of the throat, 
is liable to thefe excrefcences ; but moft 
frequently they originate from that part 
of the membrane of the nofe which lines 
or covers the ofTa fpongiofa. In ge- 
neral they are confined to one fide of the 
nofe, and they do not commonly appear 
fo far back as the throat ; but in fome in- 
ftances they occupy both noftrils, and in 
others they are fo large as to be diftinctly 
perceived on looking through the mouth 
into the pharynx. In fome cafes, indeed, 
they are found to originate from the pha- 
rynx. 

The 



Sect. V. Nofe and Fauces. gi 

The firft warning which a patient com- 
monly receives of this difeafe, is a partial 
lofs of fmell, attended with a fenfation of 
fulnefs or obflruction in fome particular 
part of the nofe, very fimilar to what is 
experienced from the fluffing of the no- 
ftrils in a common cold or catarrh. This 
continues to increafe, till afmall tumor or 
excrefcence is perceived in one, and fome- 
times in both, noftrils ; which in fome in- 
ftances never defcends farther than to be 
merely perceptible when the head is fome- 
what elevated ; while in others it falls a 
confiderable way down upon the upper 
hp, and at the fame time perhaps pufhes 
back into the throat. 

In fome this elongation of the tumor 
continues fteady and permanent, but in 
moft inftances the fwelling retracts alto- 
gether within the noftrils in dry weather, 
and protrudes only in rain; and more 
efpecially in thick hazy weather. Indeed, 
the influence of weather on the fize of 
thefe excrefcences is often aftonifliing, I 
have known fome patients who in clear 
G 2 dry 



92 Difeafes of the Ch. XXVIII. 

dry weather were not known to labour 
tinder the difeafe, in whom the fwellings 
always protruded to a confiderable length 
on the leaft tendency to a damp atmo- 
fphere. 

Excrefcences of this nature are of various 
degrees of firmnefs. A great proportion 
of them are foft and compreflible, but in 
fome inftances they are extremely firm ; 
and at Jafl have been known to acquire 
even a cartilaginous kind of hardnefs. 
Both kinds of them are apt t© bleed on 
being fretted or roughly handled : But it 
is thofe of a foft fpongy nature only which 
are fo remarkably affected by the weather, 
the firmer or flefhy kind of polypi being 
Teldom or never influenced by it. 

The colour of thefe excrefcences is like- 
wife variable : For the mod part they are 
Jfomewhat pale and tranfparent, but in 
fome inftances they are of a deep red co- 
lour ; and, fo far as I have yet had oppor- 
tunities of obferving, I would fay, that 
there is fome connection between the co- 
lour and confidence of them. The expe- 
rience 



Sect. V. Nofe and Fauces. 93 

riencc of others may lead to a different 
conclufion ; but in the courfe of my ob- 
servation it has uniformly happened, that 
the foft compreflible polypus has been of 
a pale complexion, while thofe of a firmer 
texture have always been of a deep red. 

In the commencement of this diforder, 
the pain attending it is always inconfider- 
able ; and in the fofter kinds of it there 
is feldom much pain, even in its moft ad- 
vanced ftages. But rhofe of a harder na- 
ture in general become painful as they in- 
creafe in fize, particularly on any caufe of 
irritation being applied to them. In feme 
inftances, they become unequal and ulcer- 
ated over their whole extent. In this ftate, 
configurable quantities of a thin fetid mat- 
ter are difcharged ; and if a cure be not 
obtained by extirpation, they are now very 
apt to degenerate into cancer. It is pro- 
per to obferve, however, that it is the firm 
flefhy kind of polypi only which are apt 
to become cancerous, and that this change 
rarely or never happens with thofe of a 
fofter texture. 

G 3 But 



94 Difeafes of the Ch. XXVIII. 

But although the fofter kinds of thefe 
fwellings very feldom terminate in cancer, 
and are rarely productive of much incon- 
venience in the early ftages of the difeafe, 
or as long as the excrefcences are confined 
to either of the nafal cavities ; in the lat- 
ter ftages of the diforder, they are often 
attended with a great deal of diftrefs. Be- 
fides the trouble and perplexity which oc- 
curs from their falling down upon the lip, 
they fometimes pafs fo far back into the 
fauces, as not only to impede deglutition, 
but to obftruct refpiration ; and in fbme 
inftances the tumors become fo large, 
as not cnly to diftend the fofter parts 
of the noftrils, but to elevate and even 
to feparate and dhTolve the firm bones of 
the nofe. This, indeed, is not a common 
occurrence j but every practitioner muft 
have met with it : I have feen different 
inftances of it. 

Various opinions are met with in au- 
thors of the caufe of polypous excrefcences. 
By fome they are faid to depend moft fre- 
quently 



Sect. V. Nofe and Fauces. 95 

quently upon a fcrophulous taint ; while 
others imagine, that a venereal infection 
often gives rife to them. 

We will not fay that fwelHngs of this 
kind do not, in fome inftances, occur 
along with the venereal difeafe and fcro- 
phula. They may even be met with 
as fymptoms of thefe difeafes. But in 
fuch inftances we would confider the ge- 
neral taint of the fyftem in no other light 
than as an occaGonal or exciting caufe of 
the local affection, for in almoft every cafe 
of polypus a local injury may be traced as 
the caufe of it ; and from every circum- 
ftance relating to the difeafe, we conclude, 
that it is always of a local and circum- 
fcribed nature. For even where a polypus 
originates from a venereal infection, this 
particular fymptom is fo far of a local na- 
ture, that it remains fixed and permanent 
after the general taint of the fyftem is com- 
pletely removed. 

All the harder kinds of polypi we fup- 

pofe may originate from the fame caufes 

G 4 which 



* 

gS Difeafes of the Ch. XXVIII. 

which produce tumors of a fimilar texture 
in other parts of the body ; but in molt in- 
fiances they appear to be connected with, 
and even to proceed from, a caries of the 
bone underneath ; and it is this chiefly 
which renders them more hazardous and 
much more difficult of cure than thofe of 
a fofter narure, which, in general, we ima- 
gine are produced by a mere diftenti- n or 
relaxation of the membranaSchneideriana, 
When any portion of this membrane be- 
comes inflamed, either by the effects of 
cold or from external violence, if in this 
flate any part of its furface is ruptured or 
eroded, as frequently happens from pick- 
ing or blowing the nofe too forcibly, a de- 
gree of weaknefs or relaxation is thus pro- 
duced, which is apt to terminate in a ful- 
nefs or prominency of the parts immedi- 
ately afFe&ed ; and this being increafed by 
every fucceeding cold, the difeafe we are 
now confidering comes in this manner to 
take place. 

The farther progrefs of the difeafe may 
depend on various caufes j but in general 

it 



Sect. V. Nofe and Fauces, $7 

it will advance quickly or flowly, accord- 
ing as the parts affected are more or lefs 
liable to inflammation. Thus I have known 
various instances of polypi of this kind re- 
maining fmall and perfectly ftationary for 
a great number of years, when the patients 
have not been obliged to be much expofed 
to the open air ; while it commonly hap- 
pens, among the poorer clafs of people, 
who are expofed to every inclemency of 
weather, and who are therefore more liable 
to frequent returns of catarrh, that the 
difeafe advances with much more rapidity. 

In the treatment of every difeafe, it is a 
matter of much importance to be able to 
form a juft prognofis, not only of the 
manner in which the fymptoms may pro- 
bably terminate, but of the effects to be 
expected from the different remedies that 
may be employed for them j and in no 
inftance is this a more defirable object than 
in the management of polypous excrefcen- 
ces of the nofe. 

By fome writers upon this fubject, we 
are led to conclude, that polypi are always 

of 



9? Lifeafes of the Cli. XXVtlt. 

of a doubtful nature with refpedl to the 
event or termination of them : That for 
the moft part they are even of a dangerous 
nature ; and therefore that we ought to 
conlider every perfon in whom they occur 
as in a hazardous ftate : Whilft others af- 
fert, that although they may occafionally 
be productive of fome inconvenience, yet 
that they are feldom attended with any 
kind of rifk. 

Some, again, are fo extremely timid 
with refpect to polypi, as to fuppofe that 
they ought never to be meddled with ; and 
alledge, that there is more chance of doing 
harm than good by any operation we can 
employ for removing them; whilft by 
others we are told that they may be taken 
away with fafety. 

This difference of opinion refpecling 
the nature of polypi, and of the effects to 
be expected from the remedies employed 
for them, has arifen in a great meafure 
from authors not having diflinguifhed the 
different kinds of thefe excrefcences with 
fuch precifion as they ought to have done : 

For 



Sect. V. Nofe and Faucet. gg 

For while in one variety of the difeafe 
there is little rifk to be dreaded, and no 
great caufe to doubt of our being able to 
remove it ; in others there is undoubt- 
edly a good deal of hazard, and much 
r'eafon to fear that no remedies whatever 
will prove effectual in preventing a return 
of it. 

We have already obferved, that thefe 
tumors are of various degrees of con- 
fidence ; and from all the experience 
which I have had in the treatment of 
them, I am led to conclude, that in ge- 
neral the rifk with which they are attend- 
ed is nearly in proportion to their firm- 
nefs. The foft compremble kind of po- 
lypi are not only lefs painful than the 
others, but the removal of them may at 
any time be attempted with more fafety. 
Indeed they are not commonly attended 
with pain; and it feldom happens that any 
material inconvenience occurs from the 
extirpation of them : But the firm flefhy 
kind of polypi are in general not only pain- 
ful, but are much more apt to return after 

being 



loo Difeafes of the Ch. XXVIII. 

being extirpated. In forming an opinion, 
therefore, of the probable event of them, 
this circumflance of texture deferves par- 
ticular confideration. In a foft, yielding 
polypus, if the conftitution is healthy, we 
may perhaps in every inftance give a fa- 
vourable prognofis : for as long as the dif- 
eafe remains of a moderate fize, there is fel- 
dom any inconvenience experienced from 
it, and therefore there is no neceflity for 
meddling with it ; and again, when, by 
acquiring a great additional bulk, the re- 
moval of the tumor is rendered neceflary, 
it may always be undertaken with much 
probability of fuccefs. But, on the con- 
trary, in polypi of a flefhy confiflence, and 
efpecially in tumors of even a firmer tex- 
ture than this, the patient or his friends 
ought always to be informed of the rifk 
being confiderable : for it frequently hap- 
pens that excrefcences of this kind cannot 
be entirely removed ; and even when this 
is eafily and completely practicable, they 
are apt to regenerate, and in fome in- 
(lances, as we already obferved, to be- 
come 



Sect. V. Nofe and Fauces, ioi 

come cancerous. In all fuch cafes, there- 
fore, a guarded prognofis ought to be 
given ; other wife, if the difeafe mould 
afterwards return, the operator would be 
juftly blameable, at the fame time that the 
operation itfelf would fall into difcredit. 

Indeed fome practitioners are fo averfeto 
this operation in all cafes of firm or hard 
polypi, that they always decline to meddle 
with them. As long as they remain fta- 
tionary, and are not attended with pain, 
if they do not obftruct the breathing or 
deglutition, they ought not to be touched: 
But whenever they become painful, and 
efpecially when they have acquired fuch 
a bulk as to obftruct either the paffage to 
the ftomach or lungs, we ought certain- 
ly to endeavour to extract them, if this be 
not already rendered impracticable by 
their adhering through the whole of their 
extent to the bones of the nofe, and by 
thefe being rendered carious ; which they 
are apt to be in the late ftages of this dif- 
order. 

All the fofter kinds of polypi which are- 

liable s 



to2 Difeafes of the Ch. XXVIII. 

liable, as we have already defcribed, to be 
affected by the ftate of the weather, may 
frequently be prevented from acquiring 
any additional bulk by the ufe of aftrin- 
gent applications, particularly by a ftrong 
folution of alum, a decoction of oak-bark, 
or the application of vinegar or ardent 
fpirits. By one or other of thefe being 
applied from time to time over the furface 
of the tumors, I have known different in- 
ftances of their continuing for a great 
length of time to give no kind of dif- 
turbance ; and, in ibme cafes where the 
remedy has been freely employed, they 
have been fhrivelled and become confide- 
rably fmaller. It mufl be acknowledged, 
however, that they have never accomplifh- 
ed a cure ; but it is a matter of no fmall 
importance our being able by gentle means 
to render any painful operation unnecef- 
fary. 

On the firft appearance, therefore, of a 
polypus, we ought by a free ufe of fome 
aftringent application to endeavour to pre- 
vent its farther increafe j but when thefe 

do 



Sect. V. Nofc and Fauces. 103 

do not fucceed, we are to confider by what 
mode the tumor may be moft effectually 
removed. 

Various methods have been propofed for 
the removal of polypi : — namely, the ufe 
of cauftic or corroding applications ; — the 
actual cautery ; — the palling of a feton or 
cord through the difeafed noftril ; — exci- 
lion with a fcalpel or fcifTars ; — the appli- 
cation of a ligature round the neck of the 
tumor ; — and evulfion or extraction by a 
proper application of the forceps. 

An ignorance of the circulation of the 
blood, and of the eafy method with which 
we are now acquainted of putting a flop 
to hemorrhagies, led in earlier times to the 
practice of removing tumors, wherever 
they were fituated, by corrofive applica- 
tions, and even by the ufe of the actual 
cautery. If this practice was conlidered 
as neceflary in other parts of the body, it 
is not furprifing to find it propofed for the 
removal of polypi in the nofe, where the 
effects of hemorrhagies were more dread- 
ed, Cauterifmg irons were therefore in- 
vented 



104 Difeafes of the Ch. XXVIIL 

vented for this purpofe, together with me- 
tallic tubes for conducting them. But 
even with the utmoft attention there is no 
poflibility of deftroying the difeafed parts 
without injuring thofe that are found. 
Remedies of this kind are therefore more 
apt to do harm than to produce any ad- 
vantage ; fo that they are now very gene- 
rally laid aiide ; as are likewife all kinds of 
corroding applications, which are equally 
liable to uncertainty, by their being apt to 
fpread to the contiguous found parts in 
the cavity of the nofe and throat. 

As it has been imagined by fome prac- 
titioners, that excrefcences of this kind may 
be removed, by inducing a fuppuration 
upon them, it has been propofed to infert 
a cord of filk or cotton into the difeafed 
noftril, and one end of it being taken out 
at the mouth, by daily drawing it back 
and forward, and by covering that part "of 
it which comes into contact with the tu- 
mor, with a flightly irritating ointment, 
thus to create fome degree of inflammation 
and confequent fuppuration over it. 

We 



Seft. V. Ng/c and Fauces. 105 

We will readily allow, that in this man- 
ner a plentiful flow of matter may be ex- 
cited ; but it is not probable that this can 
have much influence in diminifhing the 
fize of the tumor. Till of late indeed, it^ 
was commonly imagined that the forma- 
tion of pus is neceflarily attended with a 
diflblution of the folid parts in which it 
occurs. Upon this principle Mr Daran and 
others have endeavoured to explain the 
operation of bougies in obftructions of the 
urethra ; and a fimilar idea fuggefted the 
remedy of which we are now fpeaking, in 
polypous excrefcences of the nofe. But ic 
is now known, as we have elfe where fully 
fhown, that the diflblution of folid parts 
is by no means neceflary for forming pus. 
It is alfo known, that in difeafes of the 
urethra, bougies prove effectual only by 
their form, and by the preflure which they 
produce; and we have no difficulty in fay- 
ing, that it is in this manner only by which 
a cord, if it ever proves ufefu!, can have 
any effect in removing polypi of the nofe. 
As the paflfage of the noftrils is very une- 

Vol. IV. H qual, 



io 6 Difeafcs of the Ch. XXVIII. 

qual, being wider in one part than another, 
and as the roots of polypi are frequently 
fo fituared that no preffure can be applied 
to them, we are not of opinion that they 
can ever be removed by a cord paffed 
through the nofe, as many have imagined. 
But after the extirpation of polypi in the 
manner we fhall afterwards point out, 
when their roots are not entirely remo- 
ved, there can be no impropriety in our 
endeavouring in this manner to clear 
the pafTage more effectually. It was for 
this purpofe folely, we may remark, that 
the practice we are now confidering was 
originally propofed by that judicious ob- 
ferver Monfieur Le Dran. But although it 
might, in this manner, fometimes prove 
ufeful, yet from being a troublefome and 
difagreeable application, ithasfeldom been 
employed. We mall have occafion how- 
ever, in a fubfequent part of this fection, 
to fpeak of it again. 

In other parts of the body, the removal 
of tumors by excifion is univerfally prefer- 
red 



Sect. V. Nofe and Fauces. 1 07 

red to every other method ; and it would 
likewife be employed in polypi of the 
nofe, were ic not for their inacceffible fitu-. 
ation. But it feldom happens that they 
are fo fituated as to render this mode of 
treatment practicable ; for although fcal- 
pels and fciiTars of various forms have been 
invented for this purpofe, the roots of po- 
lypi are in general feated fo high in the 
noftrils, and the pafTage is for the mod 
part fo completely filled by the tumor 
itfelf, as to render it always difficult, and 
often impoffible, to remove them by ex- 
cifion. 

But when it is found that the tumor 
originates from the under part of the 
noftril, and when the point of a fcal- 
pel can be made to reach the root of ir, 
we ought, without hefitation, to employ 
this method of taking it away, even in pre- 
ference to that by ligature : for in this 
manner the whole of the tumor may be 
more effectually removed; and in thisfitu- 
ation there is no reafon to be afraid of he- 
morrhagica, as compreffron can be readily 
H 2 applied 



i o8 Difeafis of the Ch. XXVIII. 

applied to any blood- vefTel that may be 
cut in the under part of the noftrils. We 
rarely find however, as has been already 
obfei ved, that a polypus is feated fo far 
down in the noftrils as to render this me- 
thod of treatment practicable. 

It therefore appears that all the means 
we have yet confidered for the removal 
of thefe excr 'fcences, are either inadequate 
for the effect, or altogether inadmiffible ; 
and hence we are under the neceffity 
of employing either the method by li- 
gature, or that by extraction with the 
forceps. 

As the removal of a polypus, by tearing 
or twilling it off, is attended with much 
more pain than the application of a liga- 
ture round the neck of it, the latter would 
always have been preferred, if it had been 
confidered as equally practicable. And as 
we now know that it can be done in a 
very fafe and eafy manner, it will proba- 
bly in future be very generally employed. 
The method we allude to, is that which 
Monfieur Levrette of Paris firft recom- 
mended, 



IM..VTI' 




Sect. V. Nofe and Fauces. 109 

mended, a considerable time ago, for the 
removal of polypi in the vagina, and which 
we now find may be nfed with equal pro- 
priety in fimilar affections of the nofe and 
throat. The following is the method of 
applying it in polypi of the throat. 

Fig. 1. Plate XLIV. reprefents a piece of 
pliable filver wire palfed through a double 
canula, and the wire fhould be long enough 
when doubled as to pafs through the nofe 
into the pharynx. Let the wire be taken 
from the canula, and the doubling at the 
end of it be flowly and gently infinuated 
through one of the noftrils : As foon as 
it appears in the throat, the operator, with 
his fingers inferted into the mouth, muft 
open the double fufficiently for palling it 
over the pendulous extremity of the tu- 
mor ; and having preffed it down to the 
neck or root of it, the two ends of the li- 
gature hanging out at the noftril muft be 
again pafTed through the canula ; which is 
now to be inferted into the fame noftril, 
and pufhed back along the courfe of the 
H 3 wire 



no 



Di/eqfis of the Ch. XXVlII. 



wire till it comes into contact with the root 
of the polypus. The fingers mould ftill 
be continued in the throat to prefer ve the 
ligature in a proper fituation ; and the ca- 
nula being placed in the manner we have 
directed, the wire mud be drawn tolerably- 
tight ; and the ends of it being fixed on the 
wings or handle of the canula, as in Plate 
XLV. fig. i. it muft be left in this fitua- 
tion till the following day, when being a- 
gain drawn ibmewhat tighter, and this be- 
ing daily repeated, the tumor will fall off 
fooner or later according to its fize. When 
the excrefcence is fmall, it will probably 
drop in the courfe of the fecond day; and 
tumors of even a large fize will come away 
on the third day. It is better however to 
nv.ke the compreflion in a more gradual 
manner: for when the wire is drawn with 
much force, inftead of acting as a ligature, 
and removing the tumor by compreflion, 
it removes it too quickly, by cutting it a- 
crofs, and may thus be equally productive 
of hemorrhagies as if the operation had 
been done with a fcalpel. 

la 



Sect. V. Nofe and Fauces. 1 1 1 

In this manner all thofe polypi may be 
removed which either originate in the 
throat, or which proceed back from the 
noftrils into the fauces ; and the practice 
may be extended even to thofe which arc 
deeply feated in the pharynx, if the liga- 
ture can be properly applied over them 
either with the fingers ; with the aflifl- 
ance of forceps ; or with an inftrument 
fuch as is delineated in Plate XLVI. fig. 3. 
Some inftances indeed have occurred of ex- 
crefcences feated too far down in the cefo- 
phagus for admitting of ligatures being ap- 
plied upon them in this manner ; nor is 
it admiflible, even where the upper part 
of the tumor is acceflible, if the bafe or 
neck of it be fo low down as to prevent the 
ligature from being applied to it. In the 
third Volume of the Phyfical and Literary 
EfTays of Edinburgh, there is a cafe related 
in which a very ingenious method was 
put in practice by the late Mr Dallas for 
furrounding a deep feated polypus with a 
ligature ; and although inftances of fuch 
excrefcences are extremely rare, yet as they 
H 4 are 



ti2 Difeafes of the Ch. XXVIII. 

are fometimes met with, I think it right to 
give a delineation of the inftrument which 
in this inftance was fuccefsfully employed. 

In this cafe both the breathing and de- 
glutition were much impeded by a large 
flefhy excrefcence originating in the cefo- 
phagus, a confiderable portion of which 
was thrown into the mouth by every ex- 
ertion to vomit ; but it foon retracted and 
remained perfectly concealed within the 
pharynx till vomiting or retching was 
again excited. This portion of the tumor 
which occafionally protruded, was entirely 
removed by the method we have mention- 
ed, and which we have more particularly 
defcribed in the explanation to Plate XL VII. 
By this means the patient was relieved 
from much inconvenience and diftrefs ; 
but another branch of the tumor which 
extended towards the ftomach becoming, 
afterwards very large, he died by the ef- 
fects of it in about two years from the 
operation. 

We think it right to remark, that this 
patient might probably have been faved 



Seel. V. Nofe and Fauces. f 15 

by the ufe of the ligature and double ca- 
nula fuch as we have defcribed, and that 
in fimilar cafes it is to be considered as 
perhaps the beft means of relief. When a 
polypus is fufpedled to have formed in the 
cefophagus, if no part of it is obferved to 
protrude up towards the pharynx, there 
will be much caufe to imagine that it pro- 
ceeds down towards the ftomach ; fo that 
if the double of a piece of flexible wire be 
pufhed down the cefophagus, the pendu- 
lous part of the tumor may very probably 
be laid hold of in withdrawing it ; or, if 
one attempt mould fail, other trials may 
fafely be made with it : And as foon as the 
double of the ligature is found to be firm- 
ly fixed, all that portion of the tumor 
which it furrounds may be eafily removed 
by the application of the double canula in 
the manner we have mentioned. It is pro- 
per, however, to obferve, that the ligature 
and canula fhould both be carried through 
one of the noftrils into the cefophagus ; 
for in this manner they will not prove 
^ nearly 



1 14. Dlfeafes of the Ch. XX VIIL 

nearly io inconvenient as when pafTed 
through the mouth, and they may be ap- 
plied with equal eafe and advantage. For 
this purpofe the canula mud have fome 
degree of curvature, as is reprefented in 
Plate XLIV. fig. 2. 

Ligatures may in general be applied 
round polypi of the back part of the nofe 
and throat in the manner we have direct- 
ed, without much interruption to the 
breathing ; but when they are deeply 
feated in the cefophagus, and on all occa- 
fions when the application of the ligature 
is difficult and tedious, it is proper to fe- 
cure an eafy and free refpiration during the 
operation by pre vioufly ad vifing bronchota- 
my. By this no additional riik is incurred, 
for it may with eafe and fafety be accom- 
plifhed ; and it puts it in our power to finifh 
the operation more perfectly than we other- 
wife could do. It is likewife proper to 
remark, that although the operation may 
often be done without any afliftance from 
a fpeculum oris, yet whenever it proves 

te- 

• 



Se<5l. V. Nofe and Fauces. I 1 5 

tedious, and when the ligature cannot 
be applied with much eafe over the tu- 
mor, this inftrument ought to be em- 
ployed. 

We have now to mention the method of 
applying a ligature to a polypus feated in 
the anterior part of the nofe, and which, 
inftead of pafling back into the pharynx, 
proceeds down one of the noftrils towards 
the upper-lip. Let the double of the li- 
gature be paned over the moft depending 
part of the polypus, and be flowly pufhed 
up to the root of it with the flit probe 
Plate XLVI. fig. 2. The probe being gi- 
ven to an afliftant to preferve the ligature 
in this fituation, the two ends of it muft 
be patted through a double canula ; which 
being inferted into the noftril on the op- 
posite fide of the polypus, and being pufh- 
ed eafily along till it reaches the root of it, 
the ligature muft now be drawn fo tight as 
to make fome impreflion on the root of the 
tumor, when the ends of it muft be tied 
to the wings of the inftrument, and muft 

be 



i 1 6 Difeafes of the Ch. XXVIII, 

be daily pulled fomewhat tighter till the 
tumor drops off. 

In this manner every polypus in any 
part of the nofe may be extirpated. Thofe 
who have not feen it put in practice may 
be apt to doubt of this affertion ; but a 
few trials will fhow that it is not only the 
moft effectual method, but the fafeft and 
eafieft that has yet been propofcd of re- 
moving every excrefcence of this kind : 
And it has the advantage over every other 
method of applying ligatures upon polypi 
in the nofe, of anfwering equally well in 
the large as in the fmaller kinds of them 
—and it may even be applied where the tu- 
mor is fo large as to diitend the noftril to a 
confiderable fize. In Plate XLVI. fig. i. 
there is delineated a remarkable form of a 
polypus extirpated in this manner under 
the direction of Dr Monro, who was the 
firft, I mud obferve, who put in practice 
this method of removing polypi from the 
nofe and fauces. This polypus filled the 
noftril completely ; to fuch a degree in- 
deed, that it could not have been removed 

in 



PLATE XLV. 




Sect. V. Nofe and Fauces, 117 

in any other manner ; not even with for- 
ceps, for the blades of the instrument could 
not have been inferted. 

Befides this, another method has been 
propofed of applying ligatures round po- 
lypi in the noftrils : By introducing a li- 
gature through the affefted noftril into the 
throat, and pafling it in fuch a manner 
that the doubling may include the root of 
the polypus, if the oppofite ends of it be 
taken out at the mouth they may be fufE- 
ciently twifted, it is alleged, for removing 
the tumor. 

In a few cafes this might poffibly an- 
fwer, but it would often fail : I think it 
right however to mention it, as it is re- 
commended by a very judicious practi- 
tioner Mr Chefelden. Fig. 2. Plate XLV. 
exhibits a reprefentation of a polypus fur- 
rounded with a ligature in this manner. 

Various forms of forceps have been in- 
vented for the purpofe of removing po- 
lypi. Thofe that anfwer the intention 
bed, and that are mod generally ufed, are 
reprefented in Plate £LVIII. Thofe of a 

ftraight 



1 18 Difeafes of the Ch. XXVIIT. 

ftraightform are intended forextracling po- 
lypi by the anterior nares, and the crooked 
forceps are employed by fome practitioners 
for the removal of thofe excrefcences which 
pafs into the throat behind the uvula. We 
have fliown indeed that polypi of this kind 
may be more eafily removed by ligature, 
but we think it right to delineate fuch 
forceps as are ufed by thofe who prefer a 
different method. 

In proceeding to extract a polypus with 
forceps, the patient ought to be firmlyfeated, 
with his head leaning back and fupported by 
an afliftant behind ; and as it is of much 
importance our being able to difcover as 
nearly as poflible the origin of the excref- 
cence, fome advantage may be obtained 
from the face being placed in fuch a man- 
ner that the light of a clear fun may fall 
into the noftril. 

In the ordinary method of performing 
this operation, the furgeon now takes the 
forceps, fig. 2. Plate XLVIII. and inferting 
one of the blades on each fide of the poly- 
pus, he carries them eafily along till he 

brings 



Sect. V. Nofe and Fauces. I ig 

brings their points as near as pofllble to the 
neck of it, when he lays hold of it firmly, 
and endeavours to extract it entire, either 
by pulling directly downwards, or by mo- 
ving the forceps from one fide of the no- 
ftril to another ; or, as fome more proper- 
ly advife, by turning or twirling the po- 
lypus round till it is completely feparated. 
By this laft method I think it probable 
that the root or attachment of the excref- 
cence will be more readily loofened than 
in any other way, at the fame time that 
that part of the lining membrane of the 
nofe will not be fo much injured as when 
the tumor is tore away by being pulled ei- 
ther in a lateral direction or perpendicu- 
larly downwards. 

, When a polypus is of a tolerably firm 
texture, if the operation be properly con- 
ducted, we may frequently be able to bring 
it all away at once : but when it is very 
foft and yielding, it commonly requires 
repeated applications of the forceps ; and 
we fhould never defift as long as any por- 
tion, 



120 Difeafes of the Ch. XXVIII. 

tion of the excrefcence remains which can 
with propriety be removed. 

It is proper, however, in this place to 
obferve, that the firft application of the 
forceps is commonly attended with fuch 
a confiderable difcharge of blood, that be- 
ginners are apt to defift before the opera- 
tion is nearly finimed, from their being 
afraid of fatal confequences from the he- 
morrhagy ; but this ought not in general 
to be regarded, as long as by a farther ufe 
of the forceps we can extract any more of 
the polypus. And even when the opera- 
tion is finifhed, if the patient is in any 
degree robuft and plethoric, fome advan- 
tage may be derived from our admitting 
of a farther difcharge, by which inflam- 
mation may be prevented, which other- 
wife might be productive of troublefome 
confequences. The hemorrhagy, how- 
ever, ought not to be allowed to proceed 
fo far as to run any rifle of hurting the pa- 
tient. This, indeed, is not a frequent oc- 
currence j for it does not fo readily happen 
as is commonly imagined by thofe who 

have 



PLATK XfA'i 



FIG. t 





pic. i. fig .11 a 



Sed. V. Nofe and Faucis. 121 

have not had frequent opportunities of fee- 
ing this operation put in practice. I will 
not pretend to fay, that inftances may not 
occur of more blood being loft by this 
operation than is proper ; but I can fafely 
affert, that it is not a common occurrence. 
When it is found, however, that the he- 
morrhagy is proceeding too far, we ought 
immediately to employ thofe means which 
we know from experience are mod effec- 
tual in putting a flop to it ; but as we 
have already treated fully of them in Sec- 
tion III. of this Chapter, it is not neceffary 
to enter upon them at prefent. 

As it fometimes happens that fome parts 
of the roots of polypus are not extract- 
ed by the forceps, we are defired by fome 
practitioners to deftroy them by inferting 
cauftic or corrofive applications into the 
noftrils immediately after the operation. 
CJnlefs, however, we can evidently fee the 
part on whicl» the cauftic mould be ap- 
plied, I am clearly of opinion that this 
practice mould not be adopted ; for other- 
wife we rauft work entirely at random, and 

Vol. IV. I will 



Sect. V. . Nofe and Fauces* 123 

cence is not entirely removed by the for- 
ceps, although, for the reafons mentioned 
above, we are averfe in this fituation to the 
application of cauftic, it may be extremely 
proper to endeavour to deftroy it by means 
of a more harmlefs nature. In this cafe„ 
the practice we have defcribed, of paf- 
fing a feton through the noftril into the 
throat might probably prove ufeful ; but 
the fame intention may be accomplished 
with more certainty by the ufe of a large 
bougie. We have already had occafion to 
remark that in the removal of obstructions 
in the urethra, bougies feem to operate 
chiefly by mechanical prefTure ; and there 
is caufe to imagine, that upon £he fame 
principle they may be employed with, 
advantage for the removal of thofe parts 
of polypous excrefcences in the noftrils 
that cannot be taken away with the for- 
ceps; Nay more, were we confulted early 
in the difeafe, before the excrefcence has 
acquired any confiderable bulk, they 
might, I think, be fuccefsrully employed in 
preventing their farther increafe ; and if 
I a duly 



1 24 Dlfcafes of the Ch. XXVIII. 

duly perfifted in, they might, in fome 
inftances, in this incipient (late of the 
affection, remove them entirely. Practi- 
tioners, however, are feldom advifed with, 
as has been already remarked, till the 
difeafe has gone too far to admit of this. 
I have only had one opportunity of trying 
it ; but in this cafe, the effects of it were 
fuch as to juftify our putting it to the teft 
of future experience. 

The perfon in whom it was employed, 
had for feveral weeks complained of a kind 
of (luffing, and interruption to breathing 
in one of his noftrils. On looking into it. 
I clearly faw and touched with the probe, 
a finally pale coloured, foft polypus, at a 
considerable depth. As it did not yet pro- 
duce much inconvenience, I did not think 
of advifmg it to be extracted ; but confi- 
dering it as a fit cafe for trying the effects 
of compreffion, a roll of bougie plafter of a 
proper fize was introduced along the 
courfe of the noftril ; and being gradually 
increafed in fize, the paffage through the 
noftril became clear and pervious j and in 

the 



Sect. V. Nofe and Fauces. 125 

the courfe of (even or eight weeks the ex- 
crefcence difappeared almoft entirely : but 
the patient was at this time obliged to go 
abroad, and I have not fince heard of him. 

In the latter part of the treatment of this 
cafe a filver tube covered with plafter 
was employed ; by which the breathing 
went freely on ; and being of fuch a length 
as to pafs entirely into the noftril, it was 
kept in with little inconveniency. The 
tube may be prevented from falling out or 
from pafling back to the throat, by a 
piece of adhefive plafter connected with 
it being applied to the upper lip, or by fix- 
ing it to a piece of narrow tape palTed 
round the head. 

In defcribing the operation, I proceed- 
ed upon the idea of the forceps in com- 
mon ufe being to be employed; and when 
the excrefcence is fmall, they anfwer the 
purpofe as well as any other : But when 
the polypus is fo large as nearly to fill the 
noftril, they cannot be either eafily or pro- 
perly applied : for the two blades of the 
forceps being both introduced at once, 
I 3 they 



1 26 Dtfeafis of the Ch. XXVIII. 

they cannot but with much difficulty be 
pufhed deep into the noftril already much 
obftructed ; and the more they are prefTed 
forward upon the excrefcence, and the 
nearer it is brought to the axis of the 
inftrument, the more widely the blades of 
it are necefTarily opened at their extremi- 
ties ; by which the tumor cannot be fo 
equally comprefTed, nor is there fuch a 
chance of extirpating the root of it by 
means of them, as if they were fo con- 
ftructed as to apply preffure equally thro* 
their whole length. 

To remedy thefe inconveniences, feveral 
improvements have been propofed ; but 
the beft I have met with is one by the very 
ingenious Dr Richter of Gottingen. A 
reprefentation of it is given in Plate 
XLVIil, fig. 3. This inftrument may be 
ufed in the ordinary way by introducing 
both blades at once when the polypus is 
fmall; but when the tumor is large, it will 
be found to anfwer better to introduce the 
blades in the fame manner as we do mid- 
wifery forceps by inferring them feparately. 

One 



Pf.ATK. XI, VIII . 




Sect. V. Nofe and Fauces, 1 27 

One of the blades being carried flowly and 
cautioufly forward alony; the courfe of the 
polypus, the other mult in like manner be 
introduced at the oppofite fide of it, fo that 
they may now be firmly locked together 
at the joint. The blades are accordingly 
made to feparate eafily, and to fix in fuch 
a manner as to admit of their being em- 
ployed in the way we have directed. 

Thefe and every other variety of forceps 
employed for this operation, ought to be 
as thin and flender in that part of them 
which is inferted into the nofe as the na- 
ture of the difeafe will admit; for I mull 
again obferve, that the ftraitnefs of the part 
in which we have to operate, is one of the 
principal difficulties we have to encounter. 
But when the forceps are made of well- 
tempered fteel, they need never be fo thicl? 
and bulky as they are commonly made. 

When, however, polypi have acquired 
a large fize, the obftru&ion they produce 
in the noftril is in fome inftances - to 
fuch a degree, that even with this and 
every other kind of attention there is no 
I 4 poflj.- 



128 Difeafes of 'the Ch. XXVIIT. 

poffibility of inferting the forceps. In fuch 
circumftances, as a confiderable fpace may 
be gained by laying the noftril open, it 
may in fome inftances be proper to divide 
the cartilaginous part, of it by a longitu- 
dinal incifion ; and, after extracting the 
tumor, to reunite the divided parts either 
by adheuve plafters or with one or more 
futures. 

At the fame time, however, that I 
mention this, I think it right to obferve, 
that it is a meafure which ought in no in- 
itance to be haftily adopted; but I alfb 
think, that it fhould not be univerfally 
condemned, as we find it to be by fome 
practitioners. I do not imagine that it 
would in every cafe prove fuccefsful : but 
when a polypus has already become fo 
large as entirely to fill the noftril ; when 
therefore no forceps can be inferted for 
removing it ; when the tumor is Mill con- 
tinuing to increafe ; and when of courfe 
there is much reafon to fufpect that it 
may terminate fatally if it be not extrac- 
ted j it will furely be better to give the pa- 
tient 



Sect.V. Nofe and Fauces. 129 

tient any fniall chance that may be deri- 
ved from the practice we have mentioned, 
than to leave him to die in mifery ; which 
in all probability he would do were no at- 
tempt made for his relief. If on laying the 
noftril open, it is found that the tumor can 
be with fafety removed with the forceps, a 
complete recovery may poffibly be obtain- 
ed ; and thus the pain which the patient 
has fuffered, and the trouble of the opera- 
tor, will be amply rewarded, whilft at the 
fame time no material injury will be done 
nor no kind of rifle incurred, if on laying 
the parts open it is difcovered that no part 
of the tumor can with propriety be taken 
away. 

In the firm flelhy kind of polypi, which 
in fome inftances degenerate into cancer, 
when it is found that the tumor is already 
ulcerated, and that the contiguous cartila- 
ges and bones of the nofe are affected by 
it, it would no doubt be imprudent to ad- 
vife the treatment we have mentioned, for 
no advantage would probably accrue from 
it j the patient would be made to fuffer a 

great 



i 3 o Difeafes of the Ch. XXVIII, 

great deal of unneceffary pain ; and the 
operation itfelf would be brought into dif- 
repute : but in the fofter kinds of the difc 
eafe, which rarely or never become cance- 
rous, and when the more external bones 
and cartilages of the nofe are not affected, 
we ought without hefitation to adopt it, 
when the tumor, as is here fuppofed to be 
the cafe, is meant to be removed with the 
forceps, and when this cannot be done in 
any other manner. 

In the cafe of a firm flefhy excrefcence, - 
which filled the noftril fo completely that 
the forceps could not be introduced for re- 
moving it, a method was put in practice 
by Dr Richter for diminifhing the fize of 
the tumor ; which to a certain degree an- 
fwered the purpofe, and afforded confider- 
able relief. A hole or opening was made 
through the centre of the excrefcence by a 
common trocar, made red hot and covered 
with a canula, being pufhed along the 
whole courfe of it. By this means a paf- 
fage was formed through which the pa- 
tient breathed eafily, and the tumor was 

much 



Sect. V. Nofe and Fauces. 131 

much lefTened ; but the Doctor was unfor- 
tunately prevented from attempting to 
complete the cure either by extraction or 
otherwife, by the patient leaving the 
place. — This cafe, however, affords an ufe- 
ful practical hint, and points out a mode 
of treatment which in tumors of this 
particular kind may in fome inftances be 
fuccefsfully employed *. 

I have thus defcribed the method of ex- 
tracting polypi of the nofe with forceps ; 
but I mult again remark, that they may- 
be removed both with more eafe and fafety 
with the ligature : and as this mode of ope- 
rating is admiflible in perhaps every cafe 
that can occur, it feems only to require to 
be more generally known to be very uni- 
verfally preferred. 

* For a more particular account of this cafe, and of 
the forceps mentioi.ed above, V. Augufti Gottlieb Ilich- 
teri Obfervationum Chirurgicarura fafciculus fecundus. 
Getting*, 1776, 



SECT. 



1 32 Difeafes of the Ch. XXVIII. 



SECTION VI. 



Of Extirpation of the Tonfils, 

nnHE Amygdalae or Tonfils are frequent- 
ly, even in a natural ftate, fo large as al- 
mod to fill up the paflage from the mouth 
to the throat. As long, however, as they 
remain found, and are not attacked with 
inflammation, any inconvenience produ- 
ced by this is not commonly of much 
importance : but tonfils of this enlarged 
fize are very apt to inflame on the patient 
being much expofed to cold ; and frequent 
returns of inflammation are often attended 
with fuch an addition of bulk as to pro- 
duce nearly a total obftruclion to the pat- 
fage of food, drink, and air. 

It is this enlarged ftate of the amygdalae 
which in general is termed a Scirrhofity of 
the Tonfils ; but we think it right to ob- 
ferve, that the term Scirrhus appears here 

to 



Sedl. VI. Nofe and Fauces. 133 

to be very improperly applied ; for, excep- 
ting the circumftance of a firm tumor, 
every other characteriftic of fcirrhus is in 
thefe affections of the tonfils very com- 
monly wanting. A real fcirrhus is attend- 
ed with frequent mooting pains, and it is 
a fwelling of fuch a nature as generally 
terminates in cancer : Now we know, that 
pain very feldom occurs in cafes of enlar- 
ged tonfils, except from inflammation: 
while in an inflamed (late, they are fre- 
quently indeed very painful ; but as foon 
as the inflammation fubfides, no more 
pain is experienced, and they remain per- 
fectly eafy and indolent till the patient is 
again expofed to cold. This, however, is 
never the cafe with fwellings of the real 
fcirrhous kind j for whenever they become 
painful, they uniformly proceed to turn 
worfe : and, again, enlarged tonfils are fel- 
dom if ever known to terminate in cancer. 
I never knew an inftance of their doing fo; 
and few practitioners, I imagine, have met 
with it. 

Mr Sharpe, when treating of this fub- 
ject, reepmmends a more frequent extir- 
pation 



1 34 Difeafes of the Ch. XXVIII. 

pation of enlarged, or what he terms Scir- 
rhous Tonfils, than what has hitherto com- 
monly prevailed ; and he is induced to do 
fo, from having obferved that the diforder 
never returns, as it too frequently does af- 
ter the extirpation of fcirrhous tumors in 
other parts. His words being much in 
point, I mall tranfcribe them. " All other 
tumors of the fcirrhous kind, whether of a 
fcrophulous or cancerous nature, are fub- 
jecl: to a relapfe ; the poifon either remain- 
ing in the neighbourhood of the extirpa- 
ted gland, or at leaft falling on fome other 
gland of the body. In this cafe, I have 
never met with one fuch inftance ; and the 
patient has always been reftored to perfect 
and lafling health *." 

MrSharpe has here communicated avery 
interefting fact ; which is rendered the 
more valuable, by coming from a man of 
character, and whofe practice was very ex- 
tenfive. By many, however, the truth of 
it has been doubted, from its being uni- 

verfally 

* V. Critical Inquiry 1 , &c. by Samuel Sharpe.— 
Fourth Edition, feiSlion VII. 



Sect. VI. Nofe and Fauces, 135 

verfally known that fcirrhous tumors fre- 
quently return in other parts of the body 
after being extirpated. It would indeed be 
furprifing to find the extirpation of fcir- 
rhous tonfils prove always fuccefsful when 
the fame operation often fails when prac- 
tifed for fimilar affections in other parts. 
But the explanation we have given fets it in 
a more diftinct point of view. Thefe tumors 
of the amygdalse, commonly termed Scir- 
rhous Tonfils, are not of the true fcirrhous 
nature ; and hence it is that they never de- 
generate into cancer, or return after extir- 
pation; and this is accordingly a very weigh- 
ty argument for removing them as foon as 
they become fo large as to impede either de- 
glutition or refpiration. Till this, however, 
takes place to a considerable degree, no 
practitioner ought to advife this operation; 
for, as it is attended with a good deal of 
pain, it ought to be avoided as long as the 
fafety of the patient does not render it 
abfolutely necefTary ; but whenever the 
tumor becomes fo large as to produce much 
interruption to the pafTage of food and 

air. 



, 3 6 • Difeafes of the Ch. XXVIII. 

air, there mould be no hefitation in recom- 
mending it. 

Different methods have been recom- 
mended for removing enlarged tonfils. — 
Some advife the repeated application of the 
actual or potential cautery : Others recom- 
mend excifion with the fcalpel or with 
crooked fciffars : And, laftly, it has been 
propofed to do the operation by ligature. 

Cauftic applications, however,fhouldhere 
be confidered as inapplicable, from the im- 
poflibility of ufing them without injury to 
the neighbouring parts ; and we are debar- 
red from the ufe of the knife and fciflars by 
the profufe hemorrhagies which have fome- 
times occurred from excifion. Neceflity 
therefore obliges us to have recourfe to the 
ligature ; and with due attention we are 
able to remove every tumor by this method 
to which the amygdalae are liable. 

In the preceding fection we have given 
a particular detail of the beft method of 
applying ligatures to polypous excrefcen- 
ces of the throat, and it likewife appears to 
be th* eafieft and beft method of forming 

ligatures 



Seel. VI. Nofe and Fauces. 137 

ligatures upon tumors of the amygdalae. 
It ought to be done with pliable-filver wire, 
but catgut of a proper ftrength will like- 
wife anfwer j and although the double can- 
nula to be pa{Ted through the nofe might 
be of a ftraight form, it will anfwer better 
if it be fomewhat crooked, as in fig. 2. 
Plate XL1V. 

The double of a ligature, formed of pli- 
able filver wire or catgut, being inferted 
into one of the noftrils, muft be pufhed 
back till it reaches the throat, when the 
operator, introducing his fingers at the 
mouth, muft open the ligature; and having 
pa(Ted it over the tumor, it muft now be 
prefle4 as much as poffible down to the 
root of it. He muft continue to preferve it 
in this fituation with his fiogers ; while an 
afliltant having inferted the two ends of 
the ligature into the canula, muft pufh it 
eafily along the noftril, till the farther end 
of it be either feen or felt in the throat; 
and the wire being now pulled fo tight as 
to fix it in the fubftance of the tumor, the 
ends of it hanging out at the other extre- 

Vol. IV. k mity 



, 3 8 . Difsafesof.thc Ch. XXVIII. 

inity of the canula mud be tied in the 
manner we have formerly directed, to the 
wings or handle of the inftrument ; and 
the ligature being made tighter from time 
to time, the fwelling will foon fall off. 

The more pendulous the tumor, the more 
eafily will the ligature be fixed. But how- 
ever broad the bafe of it may be, there will 
feldom much difficulty occur with it ; for 
the fwelling is always very prominent : fo 
that when the double of the wire is fairly 
paffed over, it may eafily be pufhed down 
to the bafe with the fingers; and being pre- 
ferved in this (ituation till it is once made 
fufficiently tight, it will not afterwards be 
in any danger of moving. 

We have advifed the ligature to be firft 
carried through the nofe before being put 
over the tumor. It might indeed be in- 
ferted by the mouth ; but in this manner 
much inconvenience would be experienced, 
from the ligature and canuia hanging 
out at the mouth during the cure. This 
method, however, may be adopted when 
any difficulty occurs in the application of 

the 



Seel. VI. Nofe and Fauces. 139 

the ligature by the mode we have men- 
tioned. 

In affections of this nature, both tonfils 
are in general nearly equally enlarged : In 
fome cafes, the removal of one of them 
will form a fufficient opening for the paf- 
fage of the food ; but when it is found ne- 
ceffary to extirpate them both, it will be 
proper to allow any inflammation or ten- 
fion that may have been induced by the 
firfl, to fubfide entirely before any attempt 
is made to remove the other. 

This mode of applying ligatures upon 
thefe tumors, is in my opinion the beft ; 
but it may often be done in a different 
manner. Let a ligature of a fufficient 
ftrength be formed of waxed thread ; and 
let this be carried round the tumor either 
with the fingers or with a fplit probe, fuch 
as is reprefented in Plate XLVI. fig. 3. A 
noofe is now to be made upon it, and a 
knot of any degree of tightnefs may be 
formed on it by fixing one end of the thread 
at the fide of the tumor in the throat with 
the inftrument, fig. 2. Plate LI. while the 
K 2 other 



14 o Difeafes of the Ch. XXVIII. 

other is firmly drawn with the other hand 
of the furgeon out at the mouth. 

This method was firft put in practice 
by Mr Chefelden ; and it has fince that 
period been recommended by Mr Sharpe 
and others. Inorderto fix theligature where 
the tumor is of a pyramidal form with a 
broad bafe, a needle with an eye near the 
point, fach as is reprefented in Plate LI. 
fig. 3. was likewife propofed by Mr Che- 
felden. A double ligature being put into 
the eye of the needle, the inflrument is 
now to be pufhed through the centre of 
the tumor near to its bafe, and the threads 
being difengaged with a pair of forceps, 
the needle mud be withdrawn. In this 
manner two ligatures are to be formed, 
each of them being made to comprehend 
one half of the tumor by one of the threads 
being tied above, and the other below.— 
The inflrument, fig 2. of the fame Plate, 
is likewife neceffary here. 

Although it is proper to mention this 
method of fixing a ligature upon tumors 
of the tonfils with broad bafes, it is not 

probable 



Sect. VI. Nofe and Fauces. I41 

probable it will be often necefTary. By- 
employing the double canula it can never 
be needed, as by means of it fuch a 
degree of force can be applied as will 
at once fix the ligature in the fubflance 
of the fwelling: And I am the more 
confident of this from finding Mr Sharpe 
of the fame opinion, even when the ope- 
ration was done in a manner by which 
the ligature could not be fo firmly fixed 
as may be done with the double canula ; 
but even when performed in this man- 
ner, Mr Sharpe obferves, " that he has ne- 
ver in one inftance found it necefTary to 
employ the double ligature recommended 
by Mr Chefelden*. " 

By whatever method, however, the o-* 
peration is performed, it may in fome in- 
ftances happen that the tumor does not fall 
off by the firft ligature ; in which cafe an- 
other muft be applied, and continued till 
the cure be completed. 

K 3 SEC- 

* Vide Mr Sharpe's Treatife on the Operations of 
Surgery, chap, xxxii. 



l 4 3 Bifeafes of the Ch. XXVIII. 



SECTION VII. 

Of the Extirpation of the Uvula. 

^T^HE Uvula, by frequent attacks of in- 
flammation, as likewife perhaps by 
other caufes, becomes in many inflances 
fo relaxed and elongated as to be productive 
of much diftrefs, not only by impeding 
deglutition, but by irritating the throat fo 
as to induce cough, retching, and even vo- 
miting. 

Any flight degree of enlargement of this 
part may in general be removed by the 
frequent uf? of aftringent gargles, com- 
pofed of ftrong infufions of red rofe leaves 
— of Peruvian bark — or of oak-bark, with 
a due proportion of alum or of the vitrio- 
lic acid : And as long as remedies of this 
kind are found to prove effectual, no other 
ihould be advifed. But when thefe fail, 
and when the tumefaction of the uvula is 
fo conflderable as to create much uneafi- 

nefs 



SeftVTI. Nofe and Fauces. 143 

nefs in the throat, along with any of the 
forementioned fymptoms, we mult depend 
on extirpation alone for the removal of 

them. 

The uvula may be extirpated either by 
excifion or by ligature. By the firft, the 
parts afFeded are quickly removed, and 
the patient obtains immediate relief; 
whereas the other is more flow in effect- 
ing the fame purpofe, and is applied with 
difficulty. But by excifion troublefome 
hemorrhagies fometimes occur, while no 
rifk whatever entues from the ufe of a li- 
gature. Some practitioners indeed alledge 
that no danger can enfue from any hemor- 
rhagy that may take place in confequence 
of the excifion of the uvula; but although 
this may in general be the cafe, yet I 
know from experience that inftances of the 
contrary fometimes occur, and that very 
confiderable quantities of blood have been 
loft by this operation. This will moft rea- 
dily happen where the uvula is much en- 
larged, and where of confequence the vef- 
fels with which it is fupplied are in an 
K 4. enlarged 



l 4 4 bifeafes of the Ch. XXVIII. 

enlarged ftate. Where the uvula is merely- 
elongated, there will feldom, I imagine, be 
any rifk of removing it by incifion. In 
this ftate, therefore, of the difeafe, excifion 
fhould be preferred ; but when the parts 
to be removed are much increafed in bulk, 
it will be better to make ufe of the liga- 
ture. 

Different inftruments have been invent- 
ed for cutting off the uvula. One of thefe, 
which has been moft frequently ufed, is 
reprefented in Plate LII. fig. i. But nei- 
ther this nor any other we have met with 
anfwers the purpofe fo well as a curved 
probe-pointed biftoury, fuch as is delinea- 
ted in fig. 3. of the fame Plate. Or the 
operation may be very eafily done with a 
pair of fciffars of the common form, or 
with a curve, fuch as is reprefented in 
Plate XL1X. fig. 1. 2. or 3. 

When any of thefe inftruments are to 
be employed, the mouth fhould be fecured 
with a fpeculum oris, fuch as is reprefent- 
ed in Plate LIV. fig. 1. ; and the uvula 
fhould be laid hold of with a pair of fmall 

forceps, 



I'l. \ II'. \1,1\ 




Sect. VII. Nofe and Fauces. 145 

forceps, or with a fharp hook, by which 
it will be more eafily cut off than if it were 
left hanging loofe in its natural fituation. 
After the operation, if much blood be dis- 
charged, it may be reftrained by the ufe 
of an aftringent gargle ; by the applica- 
tion of ardent fpirits ; or even by touching 
the bleeding vefTel with lunar cauftic. It 
will feldom happen, however, that any 
precaution of this kind is neceflary ; for a 
moderate flow of blood will never do 
harm, and more than this will rarely oc- 
cur where the parts are not much enlar- 
ged. When, again, the ligature is to be 
employed, the mode of fixing it defcri- 
bed in the laft fecYion may be adopted : 
It may be done by the double canula 
paffed through one of the noftrils ; — 
or the canula may be introduced at the 
mouth ; — or it may be done by the me- 
thod employed by Mr Chefelden for ap- 
plying ligatures upon the tonuls, which is 
likewife defcribed in the lafl: fedtion. Af- 
ter pafling the ligature round the tumor, 
which in general will be eafieft done 

with 



146 Difeafes of the Ch. XXVIII. 

with the fingers, a knot may be tied upon 
it in the manner we have there directed, 
■with the inftrument, fig. 2. Plate LI. 

I have likewife thought it right to re- 
prefent another inftrument, which hitherto 
has been almoft the only one employed for 
fixing a ligature upon the uvula, Plate XLl V. 
fig. 3. From the name of the inventor, it has 
commonly been termed the Ring of Hil- 
danus. The invention is very ingenious ; 
and by means of it a ligature may be firm- 
ly applied upon the uvula : but the fame 
intention may be accomplifhed in a more 
fimple manner by either of the other me- 
thods defcribed above ; fo that this will 
probably be laid afide. 



section vnr. 

Of Scarifying and Fomenting the Throat. 

TT frequently happens in inflammatory 
aiFeclions of the amygdalae and conti- 
guous parts, that fcarifications are found 

ne- 



Sect. VHL Nofe and Fauces, 14.7 

neceffary ; in the firft place, for leffening 
the degree of inflammation by inducing a 
topical difcharge of blood ; and afterwards 
for the difcharge of matter contained in 
abfcefTes, when fuppuration has not been 
prevented by the means ufually employed 
for this purpofe. 

In Volume II. Plate XXIV. I have de- 
lineated an inftrument for this purpofe ; 
and other two of different forms are re- 
prefented in Plate JLIII. figures 1. and 3. 
The wings with which fig. 1. is furnifhed 
are particularly well adapted for compref. 
fing the tongue, while the fcarificator is 
employed in the back part of the mouth. 
By either of thefe, as well as with the 
other, in Plate XXIV. fcarifications may 
be made, or abfcefTes may be opened, in 
any part of the mouth or throat with per- 
fect fafety. 

In the treatment of inflammatory affec- 
tions of thefe parts, we often find it necef- 
fary to recommend fomentations ; a re- 
medy, too, which proves frequently highly 
ferviceable in catarrhal affections of the 

trachea 



148 Difeafes of the Ch.kXVIII. 

trachea and lungs. Various methods are 
propofed for conveying warm fleams to 
thefe parts ; but the beft we have ever 
feen, and it is likewife the neateft and moft 
fimple in its conftruclion, is the inftrument 
delineated in Plate LIII. fig. 2. the inven- 
tion jof Mr Mudge of Plymouth. By 
means of it, the throat, trachea, and lungs, 
may be very effectually fomented by draw- 
ing warm fleams into them, and without 
any difficulty or inconvenience to the pa- 
tient, who may lie in bed during the whole 
operation.— This inftrument I confider asr 
£b highly ufeful in the treatment of every 
cafe of catarrh, that I think every family 
fhould be pofTefTed of it. 



CHAP. 



Sect. I. Difeafes ofthet-Lips. 149 



HAPTER XXIX. 



Of Diseases of the Lips. 



SECTION I. 



Of the H a r e-l 1 p. 



NAtural tleficiences are not fo fre- 
quently met with in any part of the 
body as in the lips. Children are often 
born with fifTures in one of the lips, par- 
ticularly in the upper lip. In fome in- 
ftances this is attended with a confiderable 
want or real deficiency of parts ; in others 

we 



IfO Difeqfes of the Lips. Ch. XXIX. 

we only meet with a fimple fifTure or divi- 
{ion of them ; whilfl in fome again, there 
is a double fifTure with an intermediate 
fpace left entire between them. Every de- 
gree of this affection is termed a Hare-lip, 
from a refemblance it is fuppofed to bear 
to the lip of a hare. 

For the moft part this fifTure or open- 
ing is confined to the lip itfelf : but in 
many inftances it extends backward along 
the whole courfe of the palate, through the 
velum pendulum and uvula into the throat; 
and in fome of thefe the bones of the palate 
are either altogether or in part wanting, 
■while in others they are only divided or fe- 
parated from one another. 

Every degree of the hare-lip is attended 
with much deformity. It fometimes pre- 
vents a child from fucking. When in the 
under lip, which is not, however, often 
met with, it is commonly attended with 
inability to retain the faliva, and it is al- 
ways productive of fome degree of impe- 
diment of the fpeech ; and when the divi- 

fion 



Sect. I. Difeafes of the Lips. 151 

fion extends along the bones of the palate, 
the patient is much incommoded both in. 
chewing and fwallowing, by the food paf- 
fing readily up to the nofe. 

Thefe are all very urgent reafons for our 
attempting a cure of this affection as early 
as poffible. Indeed, when fucking is in- 
terrupted by it, the child muft either be 
fed by the fpoon, or the operation muft be 
done immediately. By practitioners in 
general we are defired at all events to de- 
lay it to the third, fourth, or fifth year ; on 
the fuppofition, that the crying of the child 
will either render it altogether impracti- 
cable, or that the means employed for ob- 
taining a cure will be thereby rendered 
abortive. 

This reafon, however, does not appear to 
be of much importance ; for till the child 
arrives at his twelfth or fourteenth year, 
when we may fuppofe him to be poJTefTed 
of fufficient fortitude for fubmitting eafily 
to the operation, the fame objection will 
be found to hold equally ftrong : Nay, a 
child of fix or eight years of age is 

in 



152 Difeqfes of the Lips. Ch. XXIX. 

in every refpect more difficult to manage 
than one of fix, eight, or twelve months. 
I am therefore clearly of opinion, that 
in a healthy child the operation mould 
never be long delayed j for the more early 
it is performed, the fooner will all the in- 
conveniences produced by the difeafe be 
obviated ; and fo far as I can judge from 
my own experience, I think that it may be 
done even in very early periods of infancy, 
perhaps in the third or fourth month, with 
the fame profpect of fuccefs as in any pe- 
riod of life. I have done it in the third 
month with very complete fuccefs. 

Practitioners all agree with refpect to 
the intention of this operation, which is 
accomplifhed by cutting off the fides of the 
fiffure fo as to reduce it to the ftate of a 
recent wound through the whole extent of 
it ; and* this being done, the fides of the 
newly divided parts are drawn together 
and retained in contact till a firm adhefion 
takes place between them. But although 
the principles on which our practice is 
founded are univerfally admitted, authors 

have 



Sect. I. Difeafes of the Lips. 153 

have entertained very oppofite opinions of 
the bed method of carrying it into exe- 
cution. By fome we are directed to em- 
ploy the interrupted future for retaining 
the fides of the fiflure : others prefer the 
twifted future : whilft by many, futures of 
every kind are faid to be improper ; and 
that a cure may be always obtained by the 
ufc of adhefive plafters, or by proper band- 
ages ; by which means a great deal of pain, 
they alledge, may be prevented, which fu- 
tures are always fure to occafion. 

This is a point of much importance, 
and therefore merits particular difcuflion; 
and more efpecially as it has been warmly 
contefted even by furgeons of reputation. 

In the treatment of every diforder, it is 
our principal object to obtain an effectual 
cure j but every practitioner will allow, 
that the eafieft mode of effecting this ought 
always to be preferred. On this principle 
much pains have been taken to fhow, that 
futures are feldom neceffary in wound? of 
any kind, efpecially in the treatment of the 
hare -lip ; and in fupport of this opinion 

Vol. IV. L ' various 



154 Difeafes of the Lips. Ch. XXIX. 

various cafes are recited of cures being ef- 
fected with bandages alone : Nay, fomer 
have gone fo far as to aflert, that in every 
inftance of hare-lip a cure may be accom- 
plifhed with more certainty by means of 
a proper bandage than when futures are 
employed ; for they alledge, that the irrita- 
tion produced by futures ferves in a great 
meafure to counteract the very purpofe for 
which they are intended. After the edges 
of the fiffure are cut off or rendered raw, 
the contraction of the adjoining mufcles is 
the only difficulty which we have to en- 
counter : and this, we are told, inflead of 
being removed by futures, is univerfally 
increafed by them ; while the fame inten- 
tion, it is faid, may be effectually accom- 
plifhed without any inconvenience what- 
ever, by a bandage applied in fuch a man- 
ner as to keep the parts intended to be 
united in clofe contact, which it does by 
iupporting the contiguous parts fo as to 
prevent the reaction of the mufcles con- 
nected with them. 

That a hare-lip may be as completely 

cured 



I' l, \ v K h . 




Seel. I. Difeafes of the Lips. 15$ 

cured with the uniting bandage, or with 
adhefive plafters properly applied, as by 
futures, we have no reafon to doubt ; and 
as this method of treatment is attended 
with lefs pain than the other, it ought in 
every cafe to be preferred if it could be re- 
lied on with equal certainty : But although 
by this means we might with much pains 
and attention be able in many inftances to 
accomplilh a cure, yet from the nature of 
the remedy there is much reafon to ima- 
gine that it would frequently fail j for in 
the cure of the hare-lip, if every point of 
the parts intended to be united be not 
kept in clofe contact till a complete ad- 
hefion takes place, our intention is al- 
ways fruftrated, and nothing will after- 
wards prove fuccefsful but a repetition 
of the operation in all its parts. The 
edges of the fore muft be again rendered 
raw, and the patient muft fubmit either to 
another application of the bandage, or 
to the ufe of futures ; which, if employed 
at firft, might have faved much trouble 
both to himfelf and to the operator : For 
L i it 



j 5 6 Difeafei of the Lips. Ch. XXIX. 

it is proper to obferve, that in cafes where 
the operation is applicable, the method 
of cure by futures, when rightly conduct- 
ed, never fails, at lead 1 have never known 
an inftance of it. It fometimes happens, 
indeed, that the deficiency or retraction 
of parts is fo great as to render it impo£- 
fible by any means to keep them in con- 
tact ; and if futures are employed in cafes 
of this kind, they will no doubt prove 
uniuccefsful : This, however, is not the 
fault of the remedy, but of the operator/ 
in ufing it in an incurable variety of the 
di fenfe. 

As I have had often occafion to put this 
operation in practice, and being at firft 
prepofleired in favour of the method of 
cure by bandages and plafters, I gave them 
both a fair trial ; and the refult was what 
I have mentioned. I found, that by this 
method a complete cure might in fome in- 
ftances be obtained, but that the greateft 
care and attention could not infure fuccefs; 
and finding that difappointments never 
occur -from, the ufe of futures when 

they 



Sea.X. Difeafes of the Lips. 157 

they arc properly employed, I have now 
laid every other method afide ; and hi- 
therto I have had no caufe to regret my 
having done fb. I mall therefore proceed 
to defcribe the operation as it is perform- 
ed when futures are employed ; and as none 
of the methods of treatment by bandages 
will ever probably be received into gene- 
ral ufe, it would be confidered as fuper- 
fluous to give an account of them : And. 
befides, our doing fo feems to be altoge- 
ther unnecefTary, as the fubjeel has already 
been fully treated of by various authors of 
reputation, particularly by Monfieur Louis 
of Paris, who has given a paper in the 
4th Volume of the Memoires of the Royal 
Academy of Surgery, which contains every 
argument that has been fuggefted in fa- 
vour of the method of curing the hare-lip 
by means of bandages. 

In proceeding to the operation, the pa- 
tient, if an adult, Ihould be feated oppo- 
fite to the light with his head properly fup- 
ported by an afliftant ; but if a child, he 
will be more firmly fecured if laid upon a 
L 3. table, 



158 Difeafes of the Lips. Ch. XXIX. 

table, and kept in a proper pofture by an 
afliitant (landing on each fide. 

The- operator is now to make an atten- 
tive examination, not only of the parts to 
be removed, but of thofe to which they 
are contiguous. The upper lip ought to 
be completely feparated from the gums be- 
neath, by dividing the frenum which con- 
joins them. This admits of the lip being 
more equally ftretched ; and when one of 
the fore- teeth is found oppofite to the fif- 
fure, if it projects in any degree, as is fome- 
times the cafe, it ought to be taken out, as 
it will irritate and flretch the parrs if it be 
allowed to remain. In fome instances too, 
efpecially when the nfTure runs through 
the bones of the palate, a fmall portion or 
corner of bone is found to project from 
one or both of the angles. This mould 
likewife be removed ; and it may be eafiiy 
done by the pliers or forceps, which ought 
to be both firm and fharp, as is reprefented 
in Plate LV1. fig. 2. 

Thefe preparatory fteps being adjufted, 
the furgeon, {landing on one fide of the pa^ 

tient, 



Seel. I. Difeafes of the Lips. 159 

tient, muft take one fide of the lip between 
the thumb and fore finger of his left hand; 
and defiring an afljftant to do the fame 
with the oppofite fide, and to ftretch it 
fomewhat tightly, he muft, with a com- 
mon fcalpel, make an incifion from the un- 
der border of the lip up to the fuperior 
part of it ; in which he muft take care to 
include not only all the parts immediately 
concerned in the fifture, but even a fmall 
portion of the contiguous found fldn and 
parts beneath : And this being done on one 
fide, a fimilar incifion muft be made on 
the oppofite fide ; which ought to be of the 
fame length with the other, terminating in 
the fame point in the upper part of the lip. 
By this means, if the operation is rightly 
done, a piece, including the fifTure com- 
pletely, will be cut out, of the form of the 
letter V inverted ; and the deficiency will 
in every part of it have the appearance of 
a recent wound. 

With a view to prevent inflammation, 

the divided arteries fhould be allowed to 

difcharge freely, efpecially if the patient is 

L 4 plethoric; 



i6o 



Difeafes of the Lips. Ch. XXIX, 



plethoric ; and this being done, the furgeon 
is to proceed to unite the fides of the fif- 
fure. In this he will be much affifted by 
defining the cheeks to be pufhed forward 
fo as to bring the edges of the wound near- 
ly into contact, although not altogether fo 
clofe as to prevent him from feeing freely 
through from one fide of it to the other ; 
the affiftant behind being directed to fup- 
port the parts in this fituarion during the 
remaining fteps of the operation. 

The furgeon is now to fee that the two 
fides of the cut correfpond exactly with 
each other ; and this being done, the pins 
intended to fupport them muft be intro- 
duced in the manner we have directed in 
defcribing the twifted future, Vol I. Chap. 
I. Sect. V. The firil pin ought to be near 
to the under edge of the lip : If pofTible, in- 
deed, it fhould be placed entirely within 
the red part of the lip, leaving no more 
fpace beneath than is merely neceflary to 
fupport it. Another pin muft be in- 
serted in the centre of the cut, and 
a third within a very little of the fu- 

perior 



II.ATV. 1.1 




Otiv.HtSculf' 



Sell. I. Difeafes of the Dps. i6"r 

perior angle of it. By fome we are advi- 
fed to ufe a greater number of pins ; but 
even in adults three are always fufficient, 
and in infants two will very commonly 
anfwer. In paffing them, they ought to be 
made to enter nearly half an inch from the 
edge of the fore ; and being carried near- 
ly to the bottom, which will be feen by 
retaining the wound open in the manner 
we have directed, they muft be again pafc- 
fed outward, in a fimilar direction and to 
an equal diftance on the oppofite fide of 
the fifTure. 

The afliftant mould be now defired to 
pufh forward the cheeks, fo as to bring the 
edges of the fore clofe together, when a 
firm waxed ligature mould be applied over 
the pins in the manner we have former- 
ly directed for the twirled future, and as 
will perhaps be better understood by fig. 3. 
Plate LVII. The furgeon mould firft 
apply the ligature to the under pin ; and 
having made three or four turns with it, 
fo as to defcribe the figure of 8, it fliould 
then be carried to the contiguous pin ; and 

being 



1 62 Difeafes of the Lips. Ch. XXIX. 

being in a fimilar manner carried round 
this pin, he is then to finifh the operation 
by carrying it to the other; taking care in 
applying it round all of them, to draw it of 
fuch a tightnefs as may retain the parts in 
clofe contact ; but not fo ftrait as to irritate 
or inflame them, as is fometimes done. 

By fome authors we are defired to make 
ufe of a feparate thread for every pin, in 
order, as they fay, to admit of one pin be- 
ing removed, if it fhould become necek 
fary, without difturbing the others. This 
however never happens to be the cafe ; fo 
that the precaution is altogether unnece£ 
fary. 

A piece of lint, covered with mucilage 
to retain it, Ihould now be put over the 
courfe of the cut, with a view to protect 
it more effectually from the air ; and it 
fhould likewife be made to cover the ends 
of the pins to prevent them from being 
entangled with the bed clothes, or other- 
wife ; and this is all the drefling or ban- 
dage which in general is neceffary. We 
are defired indeed by many, after the pins 

are 



SedV. I. Btfeafes of the Lips. 163 

are all fecured, to apply the uniting ban- 
dage, in order to fupport the mufcles of 
the cheek, fo as to prevent the pins from 
cutting or irritating the parts through 
which they are pafTed, which they are apt 
in fome degree to do, when the deficiency 
of parts produced by the difeafe is confi- 
derable. 

I This however is a pra&ice which I have 
never obferved any advantage arife from, 
and it often does mifchief j for a bandage 
cannot be applied wich fuch tightnefs 
as to give any fupport to the mufcles of 
the cheek without incommoding the pa- 
tient exceedingly: and it is apt to do 
harm, as we have elfewhere obferved, by 
preffing upon the ends of the pins over 
which it muft pafs ; for even allowing a 
flit to be made in that part of the bandage 
correfponding to the lip, as fome have ad- 
vifed, this inconvenience of its preffing 
upon the pins cannot be altogether pre- 
vented : And befides, although a bandage 
may be applied fumciently tight at firfl, 
the motion of the jaw commonly loofens 

it 



164 Difeafes of the Lips. Ch. XXIX. 

it foon, fo as to prevent it from having 
any farther effect. When, however, there 
is a great deficiency of parts, and when the 
edges of the fore are with difficulty brought 
together, fome advantage may be derived 
from a proper application of adhefive pla- 
fters. An oblong piece of leather, fpread 
either with common glue, or with ftrong 
mucilage, fuch as is employed in making 
the court plafter, being applied over each 
check, and of a fize fufKcient for reaching 
from the angle of the jaw to within an 
inch or thereby of the pins on each fide, 
and each piece of leather having three firm 
ligatures fixed to that end of it next the 
pins, one at each corner and another in 
the middle, the cheeks mould now be fup- 
ported by an affiftant, when the ligatures 
fhould be tied fo as to retain the parts in 
this fituation; and if care be taken to make 
the ligatures pafs between the pins, and 
not immediately over them, no harm or 
inconvenience will occur from them. It 
rarely happens however that any affiftance 
of this kind is needed j for I have, in al- 

moft 



Sect. I. Difeafes of the Lips. l6*J 

mod every inftance, found that the pins 
anfwer extremely well without any fup- 
port whatever. 

It is fcarcely necefTary to obferve, that 
during the time the pins are in the lip, the 
patient mould be fed upon fpoon meat, 
and fhould be prevented from laughing^ 
crying, or from ftretching his mouth in 
any manner of way. 

The pins having remained in the lip for 
five or fix days at fartheft, they mould now 
be taken out ; for by this time, as I have 
found by experience, the mod perfect 
union of the parts is produced ; and by 
remaining longer they are apt to leave 
marks which do not fo readily difappear 
as when they are taken out fooner. I be- 
lieve, indeed, that three days would fre- 
quently prove fufficient ; but as I know 
from experience that the pins may with- 
out detriment be allowed to remain in the 
fore for five or fix days, I think it better 
not to remove them fooner. 

This is the practice we wifh to advife 
for a common cafe of hare-lip j and, as a 

far- 



1 66 Difeafes of the Lips. Ch.XXlX, 

farther illuftration of it, fome figures are 
delineated in Plate LVII. reprefenting 
the appearance of the difeafe before the 
operation — the parts which ought to be 
removed — the application of the pins — 
and the appearance which the parts mould 
have when the operation is finifhed. But 
for a more particular account of thefe, we 
mud refer to the explanation of the Plate. 
What we have hitherto been faying re- 
lates to the difeafe in its mod ordinary 
form. In the cafe of a double hare-lip, 
there is a neceflity lor performing the ope- 
ration twice in all its parts ; firft in one 
fhTure and then in the other. By fome we 
are directed to do them both at once : but 
this ought by no means to be attempted ; 
for by doing fo we incur much rifk of 
lofing all the advantage that may be de- 
rived from the intermediate found parts, 
and of which I once met with a very dif- 
agreeable inftance. The found part of the 
lip lying between the two fhTures was by 
no means inconfiderable, but being much 
ftretched with a great number of pins 

panned 



Seel. I. Difeafes of the Lips. \6j 

pafTed through it, it began to inflame im- 
mediately after the operation ; and the in- 
flammation and pain increafing, the whole 
pins were obliged to be removed, and the 
patient would not afterwards fubmit to 
any farther trial. We ought, therefore, 
firft to complete the cure of one fiflure ; 
and this being done, we may in the fpace 
of two or .three weeks venture with much 
lafety on the other. 

In defcribing this operation, we have de- 
fired, that although the filTure may not ex- 
tend the whole breadth of the lip, yet that 
the cut fhould pafs up to the upper part 
of it : And any perfon accuftomed to this 
operation will know, that the parts may 
be united much more neatly in this man- 
ner, than when the lip is only cut through 
part of its breadth. By the one method 
of treatment, the parts when drawn toge- 
ther are fmooth and equal ; but by the 
other, they are apt to be uneven and much 
puckered. 

We have alfo defired that the furgeon 
fhould take particular care to make the 

two 



1 68 DifeafesoftheLips. Ch. XXIX. 

two fides of the cut exactly of an equal 
length : a point of much importance in 
this operation, and requires more atten- 
tion than is commonly paid to it : for it 
is obvious, if one fide of the wound be 
longer than the other, that the cicatrix 
will not be fmooth and even as it ought 
to be : by inferting the firft pin at the 
edge of the lip, this part of it will be 
very properly united, but the reft of it 
will have a very difagreeable appea ance. 
The moft effectual method of guarding 
againft fuch an occurrence is the mark- 
ing with fmall dots of ink, not only the 
length of the cut on each fide, but the 
direction which it ought to take, by 
which every chance of going wrong is 
prevented. 

It is of much importance to have the 
lip equally and tightly ftretched in ma- 
king the incifion, otherwife the edges of the 
fore will be ragged and uneven : This may 
be always prevented by proper attention ; 
bet with a view to guard againft it as 
much as pofuble, curved forceps may be 

em- 



Sect. I. Difiafes of the Lips, 169 

employed for laying hold of the lip. They 
are delineated in Plate LV. fig. 1. They 
fhould be made fo as to comprefs the lip 
equally; and being applied in the direction 
intended for the incifion, the fcalpel fhould 
be carried along the fide of them, by which 
means the cut may be made very exact 
and even. Various forms of this inftru- 
ment have beea recommended ; but the 
one we have delineated is of a more fimple 
construction, and anfwers the purpofe 
equally well, if not better than any of 
them. 

By fome we are defired not to employ 
any initrument of this kind, on the idea 
of its irritating and bruifing the lip. 
Tnis fufpicion, however, can have occur- 
red only to thofe who have never ufed 
it ; for when it is fmooth and equal 
in every part, a degree of compreffion 
may be employed with it perfectly fuf- 
ficient for fixing the lip without creating 
the lead uneafinefs to the patient. This 
I can aflert from much experience of its 
utility. 

Vol. IV. M la- 



170 Difeafes of the Lipi. Ch. XXIX. 

Inftead of making the incifion in this 
manner, fome have directed it to be done 
by fitting a piece of pafteboard, lead, or 
tin, to the gums beneath ; and the lip 
being placed upoij it, to cut down with a 
fcalpel upon the (importing fubftance : The 
operation may be very properly dene in 
this manner, but the" cut is more eafily 
made in the manner we have directed. 

Till of late the incifion in this opera- 
tion was commonly made with fcifiars ; 
and although they are now very generally 
laid afide on the fuppofition of their brui- 
fing the lip, yet the operation may be very 
properly done with them. I would not 
think it right to employ fcifTars to cut a 
part of much thicknefs, but the lip is fel- 
dom fo thick as to render it improper to 
ufe them in cutting for the hare-lip. 
They have of late been ufed in this place 
by different practitioners ; and as a point 
of this kind can be determined by ex- 
perience alone, 1 have likewife employ- 
ed them. In order to afcertain which 
of the two modes of operating, that with 

the 



Vr, \ r r, uir 




Seel. I. Dlfeafes of the Lips, 171' 

the fcalpel or with the fciflars, ought 
to be preferred, I in one cafe made the in- 
cifion in one fide with a fcalpel, and in 
the other with fciflars. The patient aver- 
red that the fciffars gave leaft pain, pro- 
bably from their making the cut in fome- 
what lefs time than is neceffary with the 
knife j and, during the cure, that tide of 
the lip which was cut with the fciffars 
neither fwelled nor inflamed more than 
the other. I dj not from this, however, 
mean to fay, that fciflars are preferable 
to the fcalpel ; I mention it only to fhow 
that the common idea entertained of them 
is ill-founded, and that the operation 
may be equally well done with both 
inftruments. Sciflars for this purpofe 
mould be very ftrong, and particularly 
firm at the joint. Th«y ought alfo to be 
highly polifhed. The fize and form of 
them reprefented in Plate LVLfig. 1. has 
been frequently ufed, and is found to an- 
fwer. 

When defcribing the Twifled Suture in 

Vol. I. I gave the preference to gold pins; 

M 2 and 



172 Difeafes of the Lips. Ch. XXIX, 

and I am ftill of opinion that they are the 
belt. When of a proper form, fuch as are 
reprefented in Plate II. figs. 2. 3. and 4. 
they pierce the lip with much eafe with- 
out any afhftance from a porte-aguille : but 
they who think that a fharper and firmer 
point than can be given to gold will an- 
fwer better, may have fteel-points added 
to them, as is reprefented in Plate LVII. ; 
and the fteel-points being moveable, they 
may be removed after the pins are paffed, 
by which every rifk is prevented of their 
wounding the contiguous parts. By fome 
practitioners, flexible needles are employ- 
ed for this operation ; but they have not 
been found to anfwer fo well as thofe which 
are firm and give fufficient refiftance to the 
ligatures. 

In pafling the needles, I have faid that 
they mould go nearly through to the op- 
pofite fide of the lip : This ought to be par- 
ticularly attended to, otherwife a fiflure 
will remain in the inner part of the lip, 
which may afterwards prove troublefome 
by the food lodging in it. And befides, 

although 



Sect. I. DiftafesoftheLips. 173 

although the difcharge of blood which 
fucceeds to this operation is always ftopt 
immediately on the parts being drawn to- 
gether by the ligatures where the pins have 
been properly introduced, yet when they 
are not palled to a fufficient depth, the 
blood will continue to get out behind, and 
may afterwards be productive of much 
diftrefs. I have feen an inftance of this 
where a very troublefome oofing of blood 
continued for feveral days after the opera- 
tion j and an inftance is recorded even of 
death enfuing from it. In order to pre- 
vent the lip from being ftretched by the 
patient fpitting, it is the ufual practice to 
defire him to fwallow his faliva with any 
blood that may be difcharged from the 
fore. In this cafe the patient complied im- 
plicitly with the directions given to him ; 
and he died from the caufe I have mention- 
ed, namely a great lofs of blood. His fto- 
mach and bowels were found rilled with 
blood which he had fwallowed *. 

M 3 There 

* Vide Memoires de l'Academie Royalle de Chirur- 
eie, Tom. IV. p. 427. 



174 Dtfeafes of the Lips. Ch. XXIX* 

There being the leaft chance of-fuch an 
occurrence, mould be a fufficient reafon 
for patients being prevented from fwal- 
lowing their fpittle after this operation, 
till it is obferved that there is no blood 
mixed with it ; but befides, it fometimes 
happens, that ficknefs and vomiting is in- 
duced even by a very fmall quantity of 
bk>od palling into the ftomach, by which 
the lip is much more ftretched than it 
would be by all the blood from the wound 
being fpit out. 

We have thus defcribed all the fteps of 
the operation for the hare-lip : and it is 
proper to obferve, that they are equally- 
applicable in the treatment of a fiflure in 
the lip by whatever caufe it may be form- 
ed ; only, in a recent cut, as the edges of 
it are already raw, all that the furgeon has 
to do is to infert the pins and apply the 
ligatures. In wounds where fuppuration 
has already commenced, there is ufually 
fome degree of inflammation upon the ed- 
ges of them : While this continues it would 
be improper to draw them together by 



Sea. I. , Difeafes of the Lips. 175 

ligatures ; but as foon as the inflammation 
fubfides, we may with much propriety in- 
fert the pins and finifh the operation in 
the manner we have directed. We are 
told indeed by many, that this practice 
will fucceed only in recent wounds, and 
that it ought not to be recommended where 
matter is already formed : 1 have often, 
however, acted otherwife : and I have uni- 
formly found, where the edges of a fqre 
have not become callous, that they have 
been united as eafily when covered with 
pus as when perfectly recent and covered 
with blood. 

In cafes of hare-lip attended with a n£- 
fure in the bones of the palate, after uni- 
ting the foft parts in the manner we have 
pointed out, fome advantage may be de- 
rived from a thin plate of gold or filver, 
exactly fitted to the arch of the palate, 
and fixed in by a piece of fjponge flitched 
to the convex fide of it to be inferted 
into the fifTure. If the fponge be infert- 
ed dry, and be properly fitted, the moi£. 
ture which it imbibes from the conti- 
M 4- guous 



lyS Dtfeafes of the Lips. Ch. XXIX. 

guous parts will in many inftances make 
it remain fufficiently firm, by which 
both fpeech and deglutition will be ren- 
dered more eafy. In fome cafes, how- 
ever, the form of the fhTure is fuch as 
prevents the fponge from haying any ef- 
fect. This always happens when the o- 
pening is wider outwardly than it is found 
to be more internally. For fuch cafes 
other means have been propofed, efpeci- 
ally thin plates with gold fprings, made fo 
as to fix upon the contiguous parts ; but 
no invention of this kind has been yet 
found "to fucceed. 



SECTION II. 

Of the Extirpation of Cancerous Lips. 

r T" , HE under lip is more frequently attack- 
ed with cancer than any other part of 
the body ; and as we know of no internal 
remedy by which the difeafe can be cured, 
the only means we employ for it is the re- 
moval 



Sect. II. Dlfeafes of the Lips. 177 

moval of the part affected. In a former 
publication, we endeavoured to mow, that 
little dependence can be placed either on 
arfenic or any of the caultic applications,- 
which have been fo much recommended 
for this purpofe ; and that we are to truft 
to the fcalpel alone for relief. 

When a cancerous fore has fpread over 
any confiderable part of the lip, and espe- 
cially when the lip is altogether affected, 
all that a furgeon can do is to remove the 
difeafed parts ; to fecure the divided ar- 
teries by ligatures, when this is found ne- 
ceffary ; and to drefs the fore as a recent 
wound from any other caufe. In this 
manner a cancer may be effectually nken 
away ; but it gives a very difagi eeable ap- 
pearance, the. under teeth and gums being 
left all uncovered; and the patient can 
neither retain his faliva, nor fwallow li- 
quids, but with much difficulty. There is 
here, however, no alternative ; for where 
the whole lip is taken away, the inconve- 
niences we have mentioned mult neceffa- 

rily 



I 7 8 Difeafes of the Lips, Ch. XXIX. 

rily enfbe, as there is no poflibility of draw- 
ing the divided parts together. 

But when the difeafe has not attacked 
any confiderable part of the lip, we may 
always have it in our power to draw the 
edges of the cut together fo as to make 
them unite with the twifted future in the 
manner defcribed in the laft fection : by 
which we not only prevent a great defor- 
mity but the patient is equally capable as 
he was before the operation, of fwallowing 
liquids and retaining his faliva : And be- 
fides, this method of treatment, as we 
have elfewhere remarked, by leaving a 
very fmall extent of cicatrix, feems to have 
fbme effect in preventing a return of the 
difeafe ; at lead this has been evidently 
the cafe with thofe that have fallen under 
my obfervation. Where the operation has 
been performed in the ufual way, without 
drawing the divided parts together and 
uniting them by ligatures, the difeafe has 
in feveral initances returned : But, except- 
ing in a very few unfavourable cafes, it 
has never returned where the hare- lip me- 
thod 



Seel. II. Difeafes of the Lips. ljg 



© 



thod of treatment has been employed. Nay 
more, this will fometimes fucceed where 
the other has failed. A man appeared at 
our Infirmary here with a cancer on the 
under lip. It had been twice removed by 
extirpation in the ufual way ; but the di£. 
eafe returned after each operation foon after 
the healing of the fore. As there was not 
fo much of the lip removed as to prevent 
the fore from being treated in the manner 
we have'directed, after taking away all the 
difeafed parts, this method was accord- 
ingly put in practice. The cure was com- 
pleted ; and I had an opportunity of know- 
ing, eight years after the operation, that 
the man remained in good health, without 
any return of his difeafe. Nor mould we 
be deterred from doing the operation in 
this manner by the difeafe being extenfive, 
if we find that the parts which have been 
divided can be drawn together and retain- 
ed by the twifled future: And this, we 
may remark, may be always done where 
the difeafe does not render it necefTary to 
remove almoft the whole lip. Thefe parts 

ftretch 



l8o Difeafes of the Lips* Ch. XXIX. 



o 



ftretch fo considerably, that in general this 
method of treatment may be adopted, al- 
though a third part only of the lip is left 
after the operation. "With refpect to the 
method of doing the operation, we mull; 
refer to the laft fection. In addition to 
what was then faid, we have to obferve, 
that all the cancerous parts ought in the 
firft place to be removed, taking care to 
form the cut in fuch a manner a will moft 
readily admit of the edges of it being ea- 
fily and neatly drawn together. When the 
difeafe is feared in the lip only, the parts 
will have nearly the fame appearance after 
this operation, as they have after that for 
the hare- lip. But when the diforder ex- 
tends to the cheek, as is fometimes the cafe, 
a longitudinal divifion of the lip will not 
only be necefTary, but a tranfverle cut in- 
to the cheek ; both to be united by pins 
and ligatures : an operation which in dif- 
ferent inftances I have put in practice with 
very complete fuccefs. 

CHAP. 



Sect. I. Difeafes of the Mouth, tti 



CHAPTER XXX. 



Of the Diseases of the Mouth„ 



SECTION I. 



Anatomical Remarks* 



BEfore we proceed to confider the di£ 
eafes which are the object of the pre- 
fent chapter, it will be proper to premife 
a fhort anatomical defcription of the teeth, 
gums, and jaws, the parts in which thefe 
difeafes are chiefly feated. 

On examining a tooth, we find it divi- 
ded into three parts j — that part of it which 

lies 



;82 Lifeafes of the Mouth. Ch. XXX. 

lies above the gums, termed the Body or 
Corona of the tooth ; — the roots or fangs, 
which the gums, in a Hate of health, cover 
entirely ; — and a kind of depreffion be- 
tween the body and fangs, juft where the 
gums commonly terminate : This is term- 
ed the Neck of the Tooth. 

The root, as well as the interior part of 
the corona, is compofed of an ofTeous kind 
of matter ; but it appears to differ from 
bone by our not being able to throw in- 
jections into it : for although we are told 
that this may be done, there is much rea- 
fon to imagine that the opinion is ill- 
founded, from the belt anatomifts having 
failed in it *. 

This ofTeous part of the teeth being of a 
foft texture, would foon fuffer and wear 
away by maftication : But nature has am- 
ply provided againft this inconvenience ; 
for we find all that part of them which lies 
€xpofed, by being above the gums, cover- 
ed 



* Vide the Natural Hiftory of the Human Teeth, 
by John Hunter, 2d edition, p. 36, &c. 



Sell. I. Difeafes of the Mouth. 183 

ed by a very firm, hard fubftance, termed 
the Enamel, which protects them effectu- 
ally againft every injury of an ordinary 
nature. This part of a tooth, befides be- 
ing much harder than bone, differs from 
it likewife in our not being able to pa(s 
the mod fubtle injection into it ; nor can 
it be tinged by feeding an animal upon 
madder or any other colouring fubftance 
as is the cafe with every bone in the 
body. The enamel is thickeft on the up- 
per furface of the teeth, efpecially in the 
grinders where it is mod needed j and it 
becomes gradually thinner as it ap- 
proaches the neck, where it terminates. 
At this part we find the commencement 
of the periofteum, which covers all the 
roots of the teeth, and is intimately con- 
nected both with them and with the fur- 
rounding fockets. 

In the interior part of every tooth we 
difcover a hollow, or cavity, correfpond- 
ing to the fize and figure of the tooth itfelf. 
It commences by a very fmall opening in 
the extremity of the root or fang, at which 

tfce 



184 Difcafes of the Mouth. Ch. XXX. 

the blood veffels and nerves of the tooth 
enter; and this canal becoming wider as it 
proceeds forwards, terminates at laft in the 
body of the tooth, where we find the cavi- 
ty filled with a pulpy kind of fubftance l 
probably formed by an expanfion of the 
blood- veffels and nerves belonging to it. 
A tooth with one root or fang has com- 
monly only one hole or opening in it; but 
fome teeth have feveral fangs, and every 
fang has a canal pafling through it, and is 
fupplied with dillincT: blood- veffels, and 
probably with ftparare branches of nerves, 
although thefe have never been clearly tra- 
ced into them. 

The teeth are fixed in what is termed 
the Alveolar Procefs of each jaw. This 
confifts of a broad thick edge, with which 
the jaws are furnifhed, divided into fepa- 
rate cells or openings for the fangs of the 
different teeth ; and the roots of the pofte- 
rior teeth being larger and more expand- 
ed than the others, we find accordingly that 
this part of the jaw is thicker and broader 
than the fore part of it. In the upper jaw 

this 



Sea. I. Difeafes of the Mouth. 18$ 

this difference, with refpect to thicknefs, is 
.increafed by the antrum Highmorianum, 
a large finus or cavity in each maxillary 
bone immediately above the large molares 
or grinders of each fide. This finus has 
no communication with the mouth, but 
it opens into the noftril between the two 
offi fpongiofa, by a canal, which in the 
fkeleton is large enough to admit a com- 
mon quill. The alveolar procefs of the 
upper jaw is divided from this cavity by 
a thin plate of bone, in which the roots of 
the pofterior molares commonly terminate; 
but in fome inftances they pafs through 
this plate into the antrum itfelf. 

The lower jaw is in infancy compofed 
of two bones, united at the chin by what 
is termed the Symphyfis of the jaw. Thefe 
bones however are foon joined fo firmly 
together, as to have the appearance of one 
continued and connected piece. Befides 
the alveolar procefs, the under jaw is on 
each fide furnifhed with other two proce£ 
fes, with which it is necefTary for practi- 
tioners to be acquainted. The anterior, 

Vol. IV. N ' which 



1 86 Difeafes of the Mouth. Ch. XXX. 

•which feems to be chiefly intended for the 
infertion of the temporal mufcle, is term- 
ed the Coronoid Procefs. It arifes in the 
form of a ridge from the outfide of the 
jaw oppofite to the two pofterior molares ; 
and proceeding backward and upward, it 
terminates in a thin fharp point : And the 
pofterior, or condyloid procefs, which is 
(hotter, thicker, and ftronger than the 
orher, terminates in an oblong head or 
condyle,, by which the articulation is form- 
ed between this bone and the head. 

The coronoid procefs gives a degree of 
ftrength and thicknefs to the external plate 
of the alveolar procefs in this part of the 
jaw that does not take place in any other part 
of it. This renders it highly improper to 
attempt the extraction of the two laft mo- 
lares by turning them outwards. They 
fhould always be pulled towards the infide 
of the mouth. Through all the reft of the 
jaw, the fockets or alveolar procefTes are 
weakeft on the outfide, although the differ- 
ence is inconfiderable j and they are in 
both fides weaker in the upper than in the 
under jaw. 

The 



Sefl.I. Diftafes of the Mouth. 1 8? 

The full number of teeth in an adult is 
thirty-two ; and as they are of different 
forms, and intended for different purpofes, 
they are accordingly diftinguifhed by par- 
ticular names. The four anterior teeth ia 
each jaw are named Incifores ; the next 
to thefe on each fide are the Canine ; and 
the five pofterior teeth on each fide are 
termed the Molares or Grinders ; the two 
firft the fmall molares, and the other three 
the large grinders. 

In childhood there are only twenty or 
twenty-four teeth, which continue till the 
fixth or feventh year, when they begin to 
drop, and are fucceeded by others which 
are termed the Adult or Permanent teeth. 
The firft fet, or milk teeth as they are com- 
monly called, as well as fome of the others, 
are formed in the jaw before birth ; but 
they do not in general appear above the 
gums till the child is feveral months old. 
In fome inftances, about the fourth or fifth 
month, but mod frequently about the 
eighth or ninth, two of the incifores ap- 
pear in the lower jaw. Thefe are com- 
N 3 moa 



488 Difeafes of the Mouth. Ch. XXX. 

monly fucceeded by two in the upper jaw, 
and the other four fore teeth appear after- 
wards, at uncertain periods, between this 
and the tenth or twelfth month. About 
the fixreenth or feventeenth month, four of 
the large molares appear ; for in childhood 
there are no fmall molares : One of thefe 
pufh out on each fide, leaving a fpace be- 
tween them and the incifores for the ca- 
nine teeth ; which being formed farther up 
in the jaw, feldom appear before the twen- 
tieth month : but about this period, or be- 
twetn this and the end of the fecond year, 
both they and other four molares have 
commonly made their appearance. 

Thefe are the periods at which the in- 
fantine fet of teeth ufually appear; but 
much variety is met with in this point. I 
have known the canine teeth appear before 
any of the molares. In one inflance they 
came forward before two of the incifores. 
In fome cafes the incifores have been ob- 
served in the fecond and third months, nay 
even at birth; whilft in others,, I have 

known 



Sect. I. Difeafes of the Mouth. 189 

known the fourteenth or fifteenth month 
pafs over before any have appeared. 

Thefe teeth continue firm till the fifth 
or fixth year. About this period they be- 
gin to loofen; and between the feventh and 
twelfth year they are commonly all Ihed 
and fucceeded by others. By this period 
too, the jaws are fomewhat lengthened, Co 
as to admit of other four molaies. Be- 
tween the twelfth and fixte'enth years four 
others appear ; and in general about the 
twentieth year the four laft of the molares 
appear, ufually named the Dentes Sapi- 
ential. 

The two fets of teeth we have defcribed 
have very different appearances, infomuch 
that we may in general know, from the 
appearance of a tooth, whether it belongs 
to the infantine or permanent fet ; and as 
this is often a point of importance, it ought 
to meet with particular attention. It is 
particularly necefTary to be acquainted 
with their appearances in the treatment of 
thofe diforders of the teeth which occur 
about the time of fliedding the nrftfetj 
N 3 for 



1 go Difcafes of the Mouth. Ch. XXX, 

for it frequently happens that we would 
have no hefitation in pulling a tooth, were 
we certain that it belonged to the fir ft fet; 
while we would rather decline to take it 
out if it appeared to be one of thofe which 
fhould continue during life. It has hap. 
pened indeed in a few inftances, that a 
third fet of teeth have appeared ; but this 
is a very rare occurrence, and is only to 
be confidered as a very unufual deviation 
of nature. 

The fockets of the teeth, and a fmall 
portion of the teeth themfelves, are covered 
with a red, firm, flefhy kind of fubftance, 
termed the Gums. This fubftance feems 
to be almoft entirely vafcular ; for the 
flighteft wound or fcratch in it is always 
attended with a difcharge of blood. The 
alveolar procefs of each jaw is entirely co- 
vered with it ; fo that we find a fmall por- 
tion of the gums between every two teeth. 
In fome difeafes, particularly in the fcur- 
vy, a partial feparation often occurs of the 
gums from the teeth ; but in a healthy 
ftate they adhere fo firmly to the necks of 

the 



Sea. II. D ifeafes of the Mouth. 1 9 1 

the teeth as to have fome effect in fixing 
them in their fockets. 

We fhall now proceed to treat of the 
difeafes of thefe parts, and of the operations 
performed uppn them. 



SECTION II. 

Of Dentition. 

TOURING the approach of the firft fet 
of teeth, and in fome inftances of that 
of the fecond, much diftrefs is frequently 
experienced from the irritation produced 
by the teeth upon the gums. For this rea- 
fon I have thought it right, before pro- 
ceeding to the difeafes of the mouth, to 
offer a few general obfervations on Den- 
tition. 

In Dentition the gums inflame and be- 
come full about the part where the teeth 
are afterwards to appear. The child is 
conftantly rubbing the gums with his fin- 
gers. The faliva is for the raoft part in- 
N 4 creafed 



19a Dijeajes of the Mouth. Ch.XXX. 

creafed in quantity ; but in a few inftan- 
ces it is otherwife, and the mouth becomes 
perfectly dry. The bowels are commonly 
very irregular, the patient being on fome 
ocean :ms extremely coftive, and on others 
diltreffed with a diarrhoea. The heat of 
the body becomes increafed, and quicknefs 
of pulfe takes place along with other fymp. 
toms of fever. Thefe are the mod fre- 
quent fymptoms attending dentition; but 
it often happens that they are accompanied 
with fubfultus tendinum, and even with 
convulfions. 

As thefe fymptoms originate from irri- 
tation, thofe means are chiefly to be de- 
pended on which are mofr. effectual in 
counteracting this. Hence we derive much 
advantage from opiates, blifters, and efpe- 
cially from warm bathing. But when 
thefe fail, which they often do, we have it 
frequently in our power to remove every 
fymptom, by making an incifion through 
the gums diredtly'upon the approaching 
tooth or teeth ; an operation ufualiy term- 
ed jfcarifying the gums. 



Sect II. Dtfeafes of the Mouth. 193 

A common prejudice prevails againft 
this operation, from an idea of its doing 
harm, in the event of a cicatrix being left 
upon the gums, which fometimes happens 
when the tooth is not juft at hand ; for it 
isfuppofed that the cicatrix will afterwards 
be worfe to penetrate than if the gum had 
not been touched. For this reafon the ope- 
ration is feldom or never done till the tooth 
is obferved to have elevated the gum con- 
fiderably : but in this we are wrong ; for 
when delayed fo long, almoft all the advan- 
tages which may be derived from it are 
loft. I have commonly obferved, that the 
very word fymptoms which occur from 
dentition take place before the teeth have 
come this length ; and that they ufually 
abate on the teeth approaching towards the 
furface of the gums, probably from the 
gums being rendered more infenfible by 
the long continued preiTure of the teeth be- 
neath. 

Whenever we have reafon to fufpecT, 
therefore, from the nature of the fymp- 
joins, that they are owing to this caufe, we 

ought 



194 Difeafes of the Mouth. Ch. XXX. 

ought without hefitation to make a free in^ 
cifion through that part of the gums where 
there is mod reafon to expect a tooth ; and 
if this incifion mould afterwards heal, an<i 
if the fymptoms fupervene again, no rifls, 
can occur from the operation being repeat* 
ed. I have frequently found it neceflary to 
cut two or three times uponthe fame tooth; 
but with a view to prevent the neceffity of 
this, I commonly make a crucial incifion 
down to the depth of the tooth, and I have 
never obferved any inconvenience to occur 
from it. We have no caufe whatever to be 
afraid of hemorrhagy. Indeed the cut fel- 
dom bleeds above a few drops, and it com- 
monly heals eafily. 

The operation may be done with a com-, 
mon lancet, or with a biftoury or fcalpel, 
the inflruments ufually employed for it : 
but it cannot be neatly done with any of 
^hem ; and befides, we are in danger, ei- 
ther with a lancet or fcalpel, of hurting 
the contiguous parts. The inftrument re- 
prefented in Plate XLIX. fig. 4. is not li- 
able to any of thefe objections j and being 

of 



Sect. II. Difeafes of the Mouth. 195 

of a fmall fize, it may be entirely conceal- 
ed in the palm of the hand. The child be- 
ing fecured by the nurfe, the furgeon with 
the fingers of one hand fhould open the 
mouth ; and conducting the edge of the 
inflrument with the fore- finger of the o- 
ther, the incifions fhould be finiflied be- 
fore withdrawing it, by making a crucial 
cut over every tooth that appears to be ap- 
proaching. The incifion, as we have al- 
ready advifed, mould always be carried to 
the depth of the tooth, fo as to lay it en- 
tirely bare ; and when this is freely done, 
the efTedls which refult from it are often 
remarkable. I have feen inftances of chil-* 
dren being inftantly relieved by this ope- 
ration who previoufly appeared to be in 
the moft imminent danger. 

It fbmetimes happens too, as we have 
already obferved, that difagreeable fymp- 
toms take place from the approach of the 
fecond fet of teeth. I have known pain 
produced over the whole jaw, attended 
with fwelling and inflammation of the 
gums and cheeks, from a fingle tooth not 

getting 



196 Difeafes of the Mouth, Ch. XXX. 

getting freely out. This happens moft 
frequently with the dentes fapientiae ; in 
fbme instances, from the ufual caufe of 
irritation produced upon the gums, which 
in the back part of the jaws are very thick; 
but in others from there not being room 
in the jaw to admit them. In the firft 
cafe, we have it commonly in our power 
to remove all the fymptoms, by making a 
free incifion directly upon the tooth ; but 
in the other this does not always prove 
fufiicient, and nothing will frequently an- 
fwer but the extraction of the tooth. 
When it is difcovered that the fymptoms 
originate from this caufe, we mould not 
hefitate about the removal of the tooth: 
for it feldom happens that any advantage 
is gained from delaying it, and the in- 
flammation induced upon the gums often 
ipreads to the throat and other contiguous 
parts ; and is thus productive of much di- 
ftrefs, which might be eafily prevented. 
When the throat inflames and fwells from 
this caufe, no other remedy will prove 
fuccefsful; and it is'often furprifing how 

foon 



Sea. III. Difeafes of the Mouth. 197 

foon the moft violent degree of inflamma- 
tion is removed by it. I have known in- 
ftances of much diftrefs in the throat re- 
lieved immediately by the removal of a 
tooth, which had obftinately refifted every 
other means for feveral weeks. 



SECTION III. 



Of the Derangement of the Teeth. 

HPHE fecond fet of teeth frequently ap- 
pear in a very irregular manner : 
Some of them will be very properly pla- 
ced, while fome are farther out upon the 
jaw, and others farther in, than' they ought 
to be. When the derangement is not very 
remarkable, it feldom meets with much 
attention ; but in fome inftances the de- 
formity produced by it is fo confiderable 
as to require the aftiftance of art for remo- 
ving it. It occurs moft frequently in the 

inci- 



ip8 Difeafes of the Mouth. Ch. XXX. 

incifores and canine teeth, feldom or never 
in any of the molares. 

Derangements of the teeth may occur 
from different caufes : — from a deficiency 
of fpace in the jaw, by which they can- 
not be all admitted in one circle ; — from a 
natural mal-conformation ; — or from fome 
of the firft fet remaining firm after the fe- 
cond fet have appeared. 

It will fometimes happen, that the teeth 
which are out of the circle will fall into it 
without any force being applied to them, 
on fpace being given to them by one or 
more of thofe which are in the circle be- 
ing pulled. When it appears, therefore, 
that the derangement is owing to any of 
the firft fet not having dropped, they 
ought to be taken out immediately ; for 
the longer it is delayed, there will be the 
lefs chance of the irregular teerh falling into 
their fituation : but when it is even owing 
to thofe of the fecond fet being too large for 
the fpace they are to fill, we fhould not hefi- 
tate in removing fome of them, for no other 
method will prove fuccefsful. When the 
teeth which occupy the natural circle of the 

jaws 



Sed. III. Difeafes of the Mouth. 199 

jaws are regular and have a good appear- 
ance, the tooth or teeth which are out of 
the circle ought to be pulled ; but when 
either of the contiguous teeth do not fill 
the place fo properly as thefe would do, or 
when they are rough or otherwife of a dif- 
agreeable appearance, it may fometimes be 
advifeable to pull one of thefe that are in 
the circle, and endeavour to bring the 
others into the range. If this be done be- 
fore the teeth have been long fixed, and if 
they are not far diftant, they will fome- 
times in a gradual manner, as we have 
faid, fall into the vacancy without any a£- 
fiftance ; but when this does not happen 
ibon from an effort of nature alone, we 
may frequently employ means for promo- 
ting it. No attempt, however, of this 
kind can be made till the body of the de- 
ranged tooth has panned freely out from 
the gums, as till then it cannot be eafily 
laid hold of. 

The ufual method of moving teeth 
which are put of the circle, is by apply- 
ing a ligature round them, and tying each 

end 



2oo Difeafes of the Mouth. Ch. XXX. 

end of it firmly to the contiguous teeth, 
and pulling it tighter from time to time : 
or a plate of gold or filver is fitted to the 
contiguous teeth, and made to furround 
the deranged teeth in fuch a manner, that 
when it is firmly prefled down by the op- 
polite jaw, it adls with confiderable force 
in bringing the teeth nearer together. This 
laft method, however, proves troublefome 
to the patient ; and the other, at the fame 
time that it will in fome degree move the 
deranged teeth towards the circle, will] 
nearly in the fame proportion draw the 
others out of it ; but we may in another 
manner apply a ligature for this purpofe 
with perfect fafety, and it is by much 
the befl we have yet feen of moving 
deranged teeth. Let a thin plate of gold, 
of a length fufEcient to pafs over four 
of the contiguous teeth, be exactly fit- 
ted to the fide of thofe teeth oppofite to 
that which is to be moved. The plate 
fhould be perforated with feveral fmall 
holes : On being applied to the teeth, and 
tied to them by a bit of waxed thread, let 

a 



1LVI V \A\ 




Se&.III. Difeafes of the Mouth. 201 

a piece of flexible wire be patted through 
two of the holes ; and the doubling of 
the ligature being carried over the tooth 
to be moved, the two ends of it mould be 
firmly drawn through the holes, and 
mould now be fixed with a pair of pliers. 
Every three or four days the ligature 
fhould be made fomewhat tighter ; and 
this being perfevered in, almort every tooth 
in this fituation may at laft be brought 
into the circle. 

It fometimes happens that a good deal of 
deformity is produced by an opening in 
the anterior part of the jaw, formed either 
by one or, more teeth being accidentally 
driven out, or from their being a natural 
want of them. When a practitioner is 
called immediately on a tooth being driven 
out, he ought by all means to replace it ; 
or if the tooth be broke, or otherwife much 
injured, he may conlult the inclination of 
the patient with refpect to the tranfplant- 
in»g of a found one from the mouth of 
another perl'on. But in matters of this 
kind the patient feldom complains till the 

Vol. IV. O part9 



202 Dlfeafes of the Mouth. Ch. XXX. 

parts affected have become inflamed and 
tumefied, when it is too late to put this 
method of treatment in practice. In this 
fituation we muft wait till the pain and 
dwelling are entirely removed ; when, if 
more than one tooth is wanting, the defi- 
ciency muft be iupplied with artificial teeth 
fixed to thofe which remain firm ; but 
when one tooth only is wanting, we may 
frequently, ni young people, be able to re- 
move the deformity by palling a ligature 
round the two contiguous teeth, fo as by 
degrees to draw them nearer together. 
Nature will frequently effect this, in fome 
degree, of herfelf: but the operation is 
commonly flow ; and befides, it is feldom 
done fo completely as when a ligature is 
employed. Bv this means the bodies of 
the teeth are equally drawn together ; but 
when the ligature is not ufed, although 
the teeth, from want of fupport, will fall 
nearly together at their points, the open- 
ing will commonly remain nearly the fame 
at their roots. 

SECT. 



Sedl. IV. Difeafes of the Mouth, 205 



SECTION IV. 



Of Gum Boils. 

nnHE gums, like all the foft parts of the 
body, are liable to abfceffes ; but col- 
leclions of matter occur more frequently 
in the gums than in other parts, from their 
being more expofed to caufes which tend 
to produce them. Abfceffes may in this 
fituation originate from cold and from ex- 
ternal violence, as well as from every caufe 
which tends to produce inflammation in 
other parts ; but they are for the moft part 
traced as the confequence of toothach : 
and they occur not only from carious 
teeth, but from inflammation at the roots 
of teeth, when perhaps in every other re- 
fpedl the teeth may appear to be found. 

A gum-boil commonly appears after a 

fit of toothach has continued for fome time. 

It begins with fome degree of pain, attend- 

O 2 ed 



304 Difeafe s of the Mouth. Ch. XXX. 

ed with a fmall tumor on the part affected. 
By degrees the cheek fwells ; and this fuell- 
ing frequently fpreads over the whole face 
fo as to produce much deformity. On 
fuppuration taking place, the fmall tumor, 
which is commonly feated on the outride 
of the gums exactly oppofite to the difeafed 
tooth, begins to point ; and if it be not 
opened, it generally burfts either through 
an opening in the fide of the gum or be- 
tween the gum and the tooth. A quantity 
of matter is now commonly difcharged, 
by which the patient in general receives 
effectual relief: But as the caufe ftill re- 
mains, the difcharge likewife continues; 
for as the difeafe is raoft frequently in- 
duced by fome* affection of a tooth, or by 
a portion of the jaw becoming carious, a 
ftillicidium of matter ufually continues, 
either till the difeafed tooth is removed, 
or till the carious part of the jaw has ex- 
foliated : Or, if the opening happens to 
cloie, the difeafe will be fbon renewed by the 
fwelling returning, and again going thro' 
all the ftages of inflammation and fuppu- 
ration 



Sect. IV. Difeafes of the Mouth. '205 

ration in the manner we have already de- 
fcribed. When indeed the difeafe is ow- 
ing merely to inflammation at the root of 
a tooth, and when the root happens not to 
be denuded of its periofteum, after the 
matter of the abfcefs is evacuated, the fides 
of it may collapfe and adhere, and a cure 
will in this manner take place : But when 
the difeafe is produced either by a carious 
tooth, or by a carious portion of the jaw, 
or even when it proceeds from inflamnaa- 
tion alone, if the root be laid bare by the 
matter, the difeafe will not be perfectly 
eradicated till the tooth or carious part of 
the jaw is removed ; for thefe will continue 
to irritate the contiguous parts in the fame 
manner with extraneous bodies of any 
other kind. In the cafe of a fpoiled tooth, 
we mould advife it to be immediately- 
removed : but when the difeafe originates 
merely from inflammation at the root of 
a tooth, before pulling it every method of 
a more fimple nature ought to be tried ; 
and the fame means which we employ in 
the treatment of abfcefles in ether parts 
O 3 fhould 



106 Difea/es of the Mouth. Ch. XXX. 

fhould be put in practice here. When a 
free opening is formed by the burfting 
of the abfcefs, we may fometimes be able 
to dry up the running, by injecting from 
time to time a little lime-water — ardent 
fpirits — tincture of mirrh — or tincture of 
Peruvian bark properly diluted. But al- 
though trials of this kind may be advife- 
able with timid patients, who will not 
fubmit to other means, we can feldom 
place much dependence upon them : The 
mod effectual practice is to lay the abfcefs 
open by an incifion from one end to the 
other, and to endeavour to heal it from 
the bottom by inferting a finall doffil of 
lint between the edges of it, to keep it open 
till it is nearly filled beneath with proper 
granulations. This is the fureft method 
of obliterating the cavity of the iflipoft- 
hume ; and when any portion of the foc- 
ket is carious, it will more readily exfo- 
liate than it would do were it ftill covered 
with the gums. 

We have hitherto been fuppofing that 

the abfcefs js feated in the gums, or be- 

/ tweea 



Sea. IV. Difeafes of the Mouth. 207 

tween the gums and the tooth, or perhaps 
that it furrounds the focket of the tooth ; 
but it often happens that more deeply 
feated abfcefTes occur, which create not 
only more immediate pain and diftrefs, 
but more fublequent rifle : for when the 
more fohd parts of the jaw oecome ca- 
rious, which they commonly do when 
the matter of impofthumes gets into 
contact with them, the cure not only 
proves tedious, but marks of a difagree- 
able nature are apt to occur from it 
externally. With a view to prevent thefe 
diltrelling occurrences, we ought not to 
folicit the formation of pus by the ufual 
method of applying warm poultices out- 
wardly ; we fhould rather, by warm fo- 
mentations taken into the mouth, and by 
the application of any warm ftimulating 
fubftance, fuch as a roafted onion, to that 
part of the gum which appears to be moft 
affedled, to endeavour to excite a fuppura- 
tion that may point into the mouth ; and 
as foon as there is reafon to fuppofe that 
O 4 matter 



ao8 Difeafes of the Mouth. Ch.XXX. 

matter is formed in the abfcefs, it ought 
to be opened without waiting for a com- 
plete fuppuration. 

In the after-treatment of the abfcefs, all 
that we can do is to preferve a free de- 
pending orifice for the difcharge of any 
matter that may form, by which any far- 
ther mifchief will be prevented, and by 
which alone we can reafonably expect a 
cure ; for even where the difeafe is con- 
nected with a carious ft ate of the jaw, gi- 
ving a free vent to the matter is perhaps 
all that art ought in this fituation to at- 
tempt. If the conftitution is otherwife 
found, this, together with the removal of 
any of the contiguous teeth that are fpoil- 
ed, and of fuch parts of the jaw as are ca- 
rious and feparate from the reft, will ulti- 
mately effect a cure if this by any means 
be practicable. But in difeafed habits of 
body, efpecially in fcrophulous conftitu- 
tions, affections of this nature are always 
productive of much diftrefs, and can fel- 
dom indeed be healed till the general dif- 
eafe of the fyftem is removed. 

SECT. 



PIRATE TiV. 



FIG 




P y.»i|.' 



Sect.V. Difeafes of the Mouth. 209 



SECTION V. 

Of Abscesses in the Antrum Maxillare. 

/^Ollections of matter may occur in 
the antrum maxillare from various 
caufes : Whatever tends to induce inflam- 
mation on the lining membrane of this 
cavity may be productive of them. Hence 
they may be induced by blows and other 
injuries done to the cheeks. Inflamma- 
tory affections of the membrane of the 
nofe, and even long-continued inflamma- 
tion of the eyes, by fpreading to the con- 
tiguous membrane of the antrum, have 
often appeared to have fome effect in pro- 
ducing collections of this kind; and much 
expofure to cold has frequently been traced 
as the caufe of them. But the mofl fre- 
quent origin of this difeafe is pain and ir- 
ritation produced in the jaw by repeated 
and violent returns of toothach. 

From this account of the caufe of the 

dif- 



ftio Difeafes of the Mouth. Ch. XXX. 

diforder, the nature of the fymptoms will 
be readily underftood. Indeed, if we make 
allowance for the nature of the parts in 
which they occur, they will be found to 
be nearly fuch as take place from inflam- 
mation and abfceffes in other parts of the 
body. At firft fome degree of pain is felt 
over the cheek of the affected fide, and this 
frequently continues for a confiderable 
time before any external fwelling is per- 
ceived. On a farther continuance of the 
difeafe this pain becomes more fevere, and 
in fome inftances fpreads to the neighbour- 
ing parts, fo as to create uneafinefs in the 
eye, nofe, and ear ; and at laft an extenfive 
hard fwelling appears over the whole cheek, 
which fooner or later points at a particu- 
lar place, moft frequently in the centre of 
the cheek, a little above the roots of the 
pofterior molares. In fome inftances, in- 
deed, the matter burfts out between the 
roots of thefe teeth and the gums, by which 
the external tumor upon the cheek is pre- 
vented from pointing. This, however, 
does not commonly happen ; and only 

takes 



Seel. V. Difeafes of the Mouth 1 1 1 

takes place, I imagine, when the roots of 
the teeth penetrate the antrum, by paffing 
through the plate at the bottom of the 
focket. For the mod part, too, as foon as^ 
matter is fully formed in the antrum, wc 
find fome of it difcharged by the corre- 
fponding noftril, when the patient lies up- 
on the oppofire fide with his head low ; 
and if this occurs, frequently, it prevents 
the external fwelling for a confiderable 
time from pointing at any particular place, 
and confequently from burfting, which it 
always would do if the matter was not 
evacuated in fome other manner. 

This difcharge of matter by the duel: 
leading from the antrum to the noftril 
does not indeed occur in every inftance ; 
but as I have met with it in feveral cafes, 
I am not inclined with Mr Hunter to con- 
fid er the obliteration of this duel as a 
frequent caufe of thefe collections*: In- 
deed I doubt if it is ever the caufe of them. 
For the moft part, they may be traced as 
the confequence of one or other of the 

caufes 

* See a Practical Treatife on the Difeafes of the 
Teeth, &c. by John Hunter, F. R. S, &c. p. 44. 



212 Difeafes of the Mouth. Ch.XXX. 

caufes we have mentioned; particularly 
of toothach, or of inflammation excited in 
fome other manner. It therefore appears 
probable, when obftructions are met with 
in this duct, that they are rather to be 
confidered as a confequence of the difeafe: 
perhaps moft frequently as the effect of 
the adhefive ftage of inflammation, than as 
the caufe of the collection. 

A difcharge of matter from one of the 
noftrils, when it fucceeds to pain and in- 
flammation of the cheek, will for the moft 
part be found to originate from an abfcefs 
in the correfponding antrum maxillare; 
but we ought to remember that matter 
may be difcharged from the noftrils from 
other caufes ; particularly from an infla- 
med ftate of the membranaSchneideriana; 
from an ozena ; from affections of the 
frontal flnufes ; and from abfceffes in the 
lachrymal fac. In forming an opinion, 
therefore, of fuch an occurrence, every cir- 
cumftance connected with it fliould be 
taken into confideration, otherwife much 
difappointment and inconvenience may 

frc- 



Sect. V. Difeafes of the Mouth. 213 

frequently occur by our treating one dik 
eafe for another. 

In the treatment of abfcefTes of the 
antrum maxillare, nothing will ever ac- 
complifh a cure but a free difcharge being 
given to the matter : indeed collections of 
matter in this fituation mould be confi- 
dered in the fame light with fimilar affec- 
tions in whatever part of the body they 
may occur. Wherever matter is difcover- 
ed, it ought to be difcharged as quickly as 
with propriety it can be done : and in no 
inftance is it more neceffary to attend to 
this than in abfcefTes of the antrum max- 
illare : for if the matter be not evacuated, 
it will diftend and elevate the bones of the 
cheek, and at laft will probably render 
them carious. 

With a view to prevent fuch a difagree- 
able occurrence, a perforation mould be 
made into the antrum as foon as there is 
fufficient evidence, from the nature of 
the fymptoms, to conclude that matter 
is collected in it. It may be perforated in 
two differents parts. In that part of it which 

projects 



214 Difeafas of the Mouth. Ch. XXX. 

projects outwardly over the two great mola- 
res ; or one of thefe teeth may be taken out 
and an opening made into the antrum, by 
perforating directly upwards in the courfe 
of one of the fangs. As moft people wifh 
to avoid the pulling of a tooth when it 
does not appear to be abfolutely necefTary, 
the perforation is commonly made in cafes 
of this kind above the roots of the teeth. 
This lenity, however, proves often hurt- 
ful ; for in this manner the perforation 
nmft be made in the fide of the antrum, 
by which a depending opening cannot be 
given to the matter ; nor can this be ef- 
fectually obtained in any other way but by 
a perforation made in the manner we have 
mentioned in the direction of one of the 
roots of the teeth. 

We have already obferved, that either of 
the two large molares may be drawn in 
order to admit of this perforation. When 
either of them is fpoiled, the difeafed tooth 
ought to be taken out; for, being carious, 
there will be fome reafon to fufpecl that it 
may have fome fhare in the formation of 

the 



Sect. V. Difeafes of the Mouth, 215 

the difeafe : but when this does not hap- 
pen, we fhould remove the fecond great 
molares, or that tooth which lies next to 
the dens fapientiae ; for although the tooth 
immediately anterior to this is fomewhat 
more acceflible, the difference in this re- 
fpecl: is inconfiderable ; and the plate of 
bone which feparates the antrum from the 
roots of the teeth being thinner in the back 
part of the jaw than in the anterior part 
of it, the perforation is accordingly more 
eafily made in it. 

On removing one of thefe teeth, iffbme- 
times happens that the matter is immedi- 
ately difcharged with freedom from the 
antrum ; owing either to the roots of the 
teeth having been naturally fo long as to 
penetrate this cavity ; or, to the matter 
having corroded the bone which feparates 
them from it. In this cafe, if the opening 
is fufficient for evacuating the matter, the 
operation, will thus be completed : but as 
it is eafily enlarged, it ought always to be 
done where there is any caufe to doubt 

that 



2i6 Difeafes of the Mouth. Ch. XXX. 

that the matter will not be difcharged 
-with freedom. But when no difcbarge 
of matter occurs on pulling the tooth, an 
opening mud be made into the antrum in 
the manner we have already advifed, by 
pufhing a fharp inftrument into it in the 
direction of one of the fangs. A common 
trocar is ufually employed for this, and in 
general the operation may be well enough 
done with it ; but the curved inftrument re- 
prefentedin Plate L. fig. 2. anfwers better. 
In making the perforation, the patient 
mould be feated on the floor oppofite to a 
clear light, and his head fhould be laid back 
upon the knee of the operator, who may 
either be (landing or fitting behind him. 
The inftrument fhould be withdrawn as 
fbon as it has entered the antrum, which 
will be eafily known by the refiftance 
being removed from the point of it. The 
matter will now flow out freely ; and 
as foon as it is all evacuated, a fmall 
wooden plug exactly the fize of the tro- 
car fhould be introduced into the open- 
ing, 



Se ft. V. D'Jeqfis of the Mouth. 2 1 7 

ing, with a view to prevent not only the 
air, but the food during maftication, from 
finding accefs to the antrum ; and if the 
plug be properly fitted to the opening, ic 
will remain fufEciently firm, while at the 
fame time there will be no rifk of its flip- 
ping in, if it be formed with a knob or 
head fomewhat larger than the reft of it. 

This plug mould be removed from time 
to time, perhaps twice or thrice in the 
courfe of a day ; by which all the matter 
will be quickly evacuated j and no more 
being allowed to collect, the difpofition to 
form it will in general be foon removed, 
and a cure will thus be obtained. But in 
fome inftances, either from much relaxa- 
tion of the lining membrane of the antrum, 
or from fome other caufe of a fimilar na- 
ture, the difcharge of matter does not di- 
minifh, but continues nearly the fame both 
in quantity and confidence long after the 
operation. In this cafe we may often for- 
ward the cure by throwing liquids of a 
moderate degree of auringency from time 
to time into the antrum. A decoction of 

Vol. IV. P • bark 



2I& Difeafes of the Mouth. Ch.XXX. 

bark is commonly employed for this pur- 
pofe : but nothing fhouid be ufed that 
contains the lead particle of folid matter, 
as there is always fomerifk,when anything 
of this kind is injected, of depositions being 
left in the antrum; and- in different inftan- 
ces I have feen mifchief occur from this. 
I commonly employ a folution of alum, 
brandy properly diluted, or lime-water. 

When the contiguous bones are all found, 
a due continuation of this practice will at 
laft arcomplifh a cure ; but when any of 
them are carious, it will be in vain to ex- 
pect: a cure till the difeafed portion either 
exfoliates, or till it diflblves and comes 
away in the matter. The introduction of 
a probe will always render us certain whe- 
ther any part of the bones in the antrum 
be carious or not ; but we may in general 
reft iatisfied 1 with refpect to this point, from 
the fmell and appearance of the difcharge. 
When the bones are carious, the matter is 
always thin and fetid, and it becomes thick- 
er and lefs offenfive as this affection of the 
bone diminiihes. 

We, 



Sect. V. Difsafes of the Mouth. l\§ 

We have hitherto been fuppofing that 
the antrum is perforated for the purpofe 
of difcharging matter collected in it ; bur 
the fame operation becomes neceffary for 
the removal of other caufes. I once met 
with an inftance of a violent blow on the 
cheek terminating in a collection of blood 
in this cavity ; and worms forming in k 
can only be removed by this operation. 
In wrftt manner worms are produced in. 
this fituation is difficult to determine ; but 
whenever their prefence is indicated by fe- 
vere pains in the region of the antrum, not 
induced by toothach or any other obvious 
caufe, there can be no rifk in making an 
opening for extracting them ; but in this 
cafe there will be no neceflity for removing 
any of the teeth. A perforation made in- 
to the antrum, immediately above the roots 
of the large molares, will anfwer the pur- 
pofe fufficiendy. We mould not however 
reft fatisfied merely with extracting fuch 
worms as appear at the opening: We 
ought to inject from time to time fuch li- 
quids into the antrum as will moil pro- 
P 2 ' bably 



220 Difeafes of the Mouth. Ch. XXX. 

bably deftroy any that may remain ; parti- 
cularly oil, a filtrated folution of afafbeti- 
da, and perhaps a weak infufion of tobac- 
co: And the perforation mould be kept 
open for a confiderable time, to prevent as 
much as poflible the riik of any worms 
being left. 

I have mentioned the only two parts in 
which I think the antrum can with pro- 
priety be opened; namely, in the direction 
of the roots of the two large molares of the 
upper jaw ; and immediately above the roots 
of thefe teeth on the outfide of the jaw, I 
think it right however to obferve, that it 
has been faid that a perforation may be alfo 
madeintotheantrumfromthenoftril. There 
is no doubt of thisbeing practicable ; but we 
might with perhaps equal propriety fay,that 
an opening may be made into it by entering 
the inftrument from the roof of the mouth. 
It is evident, however, that it would not be 
fo proper to perforate the antrum in either 
of thefe parts as in thofe we have mention- 
ed; and therefore I would not have thought 
it neceflary to tafce notice of them, were it 

not 



Sect. V. Dtfeafes of the Mouth. aai 

not with a view to give my opinion of this 
method of making an opening from the 
noftril ; which being propofed by very re- 
fpectable authority, I think it right that 
the younger part of the profeflion, for whom 
this is chiefly intended, mould know that 
there is much caufe to doubt of the pro- 
priety of it *. 

By purfuing the means we have recom- 
mended, almofl: every diforder arifing from 
collections of any kind in the antrum max- 
illare may be completely carried off: But 
the antrum is liable to fwellings of a dif- 
ferent kind, of a much more dangerous 
nature, and which frequently do not ter- 
minate but in the death of the patient. 
They feem to originate from an enlarge- 
ment of the bones of the cheek. No matter 
is found in the antrum ; and therefore no 
advantage is derived from any perforation 
that is made into it. I have in different 
inftances, indeed, obferved much mifchief 
P 3 enfue 

* V. The Natural Hiftory of the Human Teetb, 
Part II. page 46. firft edition. By John Hunter, 
f. JL S. &c. 



223 Difeafes of the Mouth. Ch. XXX. 

enfue from it : for thofe who are not much 
accuftomed to this branch of practice are 
apt to be mifled by the appearance of thefe 
fwellings ; and, fufpecting that they con- 
tain matter, they very commonly make 
perforations into them, which frequently 
aggravates all the fymptoms, by occafion- 
ing a more rapid increafe of the difeafe. 
We ought therefore to be attentive in en- 
deavouring to diftinguifh fwellings of this 
kind from real collections of matter in the 
antrum. In abfcefTes of this cavity the 
cheek feldom fwells to any great extent ; 
and when the difeafe has been of long du- 
ration, if the matter does not find an open- 
ing into the noftril, or along the roots of 
the teeth, it commonly points towards the 
mod prominent part of the cheek. But 
when no matrer is collected, and when the 
difeafe proceeds from fome affection of the 
bones, the fwelling by degrees arrives at a 
confiderable fize, but it fpreads equally 
over the whole cheek, without pointing at 
any particular part, excepting in the very 
lateft ftages of it, when the furrounding 

foft 



Sect.V. Difeafa of the Mouth, 223 

foft parts becoming affedled, fuppuration 
fometimes occurs in them. Till the fkin 
becomes inflamed, which never happens ex* 
cept where the difeafe has been of long con- 
tinuance, the fwelling remains quite colour- 
ipfs. But the moft characteristic mark of 
it is a remarkable degree of elafticity which 
it acquires. The bones yield to preflure ; 
but they inftantly return to their Situation 
on the finger being removed ; and if in this 
ftate an incifion be made into them, which 
1 have known done, they are found to be 
reduced to a foft cartilaginous ftate, and in 
the advanced ftages of the difeafe to a con- 
fidence fomewhat gelatinous. 

This kind of fwelling is of a nature Co 
very obflinate, that hitherto I have fcarce- 
ly known any advantage refill t from any 
remedy that has been employed in it. 
In a few cafes where carious teeth have 
appeared to have fome effect in produ- 
cing it, the removal of them has put a tem- 
porary flop to the progrefs of the difeafe : 
but even this has never produced any 
permanent advantage ; I mean in the real 
P 4 difeafed 



224 Difeafes of the Mouth. Ch. XXX. 

difeafed flate of the bones we are now con- 
sidering : for the cheek is, like other parts 
of the body, liable to fwellings of a more 
harmlefs nature, which yield to the reme- 
dies commonly employed for them. But 
in this no benefit occurs either from in- 
ternal medicines or external applications. 
Long continued gentle courfes of mercury, 
along with decoction of mezereon, I have 
fometimes thought have proved ufeful; 
but the good effects refulting from thenv 
have never been of long duration. 



SECTION VI. 

Of Excrescences on the Gums. 

r "THE gums are liable to excrescences of 
different degrees of firmnefs. They 
are all of a red colour, nearly the fame 
with the gums themfelves ; but fome of 
them are foft and fungous, while others 
are firm, and even of a hard warty nature. 
In fome cafes, they are attended with pain ; 



I 



PLATE i\ 




Sedl. VI. Dlfeafes of the Mouth. ii$ 

but for the moft part they create no far- 
ther inconvenience than an impediment in 
fpeech and maftication. They are met 
with in both jaws, but moft frequently in 
the under jaw and in the infide of the 
teeth. In fome inftances they are con- 
nected to the gums by a fmall neck, but in 
general they adhere firmly through their 
whole extent. 

Excrefcences of this kind frequently 
originate from carious teeth, and in a few 
inftances from a carious (late of the al- 
veoli j in which cafe the removal of the 
fpoiled teeth, and the fubfequent exfolia- 
tion of the carious part of the jaw, will 
often accomplifh a cure. Like fungous 
excrefcences in other parts of the body de- 
pending on a carious bone beneath, as foon 
as the deceafed part of the bone is removed 
the excrefcence ufually begins to fhrivel, 
and at laft commonly difappears altogether: 
but when this does not happen, the tumor 
fhould be removed as foon as it proves in 
any degree troublefome ; and this fhould 
be the more readily propofed, as the opera- 
tion 



426 Difeafes of the Mouth. Ch. XXX. 

tion is attended with very little rifk. With 
thofe not accuftomed to this branch of 
practice, an averfion indeed prevails againft 
meddling with tumors of this kind, either 
from an idea which almoft univerfally 
takes place of their being of a cancerous 
nature, that will probably be rendered 
worfe by an operation ; or from a fear of 
the hemorrhagy that will fucceed to the 
extirpation proving troublefome. We know 
from experience, however, that there is 
in general no caufe to be afraid of either 
of thefe circumftances. I have extirpated 
feveral tumors of this kind ; and 1 never 
knew an inftance of a cancer fucceeding 
to it, or of any hemorrhagy of much im- 
portance. 

, When the excrefcence is attached to the 
gums by a narrow neck, it mould be re- 
moved by pafling a ligature round it of a 
fufficient tightnefs for making it drop off; 
but when it is connected to the contiguous 
parts by a broad bafe, we are under the 
neceflity of taking it away with the fcalpel. 
The actual and potential cautery ufed to be 

employed 



Sed. VI. Difeafes of the Mouth. <i.ij 

employed for this purpofe ; but as this 
pra&ice is now laid afide, and will not 
readily be revived again, we do not think 
it neceflary to defcribe it. 

In proceeding to the extirpation of the 
tumor, the patient fhould be firmly feated 
oppofite to a clear light, and the head 
mould be fupported by an affiftant Hand- 
ing behind. If he is^pofTefled of fufficient 
refolution, there will be no need of inftru- 
ments for keeping the mouth open ; but 
where this cannot be with certainty de- 
pended on, which is commonly the cafe 
with children, a fpeculum oris becomes 
abfolutely necefTary. There are various 
forms of this inftrument. The one in 
common ufe is reprefented in Plate LIV. 
fig. 3. ; but it occupies too great a fpace in 
the mouth to admit of a free application 
of other inftruments. To obviate this, I 
fome time ago propofed the one delineated 
in the fame plate, fig. 1.; and it has by 
experience been found to anfwer. 

A common fcalpel will for the mod 
part anfwer for duTecting off the tumor ; 

but 



228 Difeafes of the Mouth. Ch. XXX. 

but an operator ought always to be pro- 
vided with others, particularly with a 
curved knife, fuch as is reprefented in 
Plate XXXVIII. fig. I. Vol. III. and like- 
wife with crooked fcifTars, fuch as are 
delineated in Plate XLIX. fig. i. and 2. j 
for in fome inftances the roots of thefe 
cxcrefcences are more eafily feparated with 
inftruments of this*4eind than with thofe 
of a ftraight form. But whatever inftru- 
ment may be employed, much advantage 
may be derived from elevating the tumor 
as much as poflible from the parts be- 
neath with a diflecting hook ; and for this 
purpofe a hook mould be ufed with two 
fangs, fuch as is reprefented in Plate L. 
fig. 3. which anfwers much better than 
the fingle hook in common ufe. In the 
courfe of the operation, care mould be 
taken to remove the difeafed parts entirely, 
at the fame time that the incifion fhould 
not be carried fo deep as to injure the parts 
beneath, unlefs the tumor be firmly and 
clofely attached to them j in which cafe, it 
may not only be proper to remove a por- 
tion 



Sea. VI. B'ifeafis of the Mouth. 229 

tion of the gums, but even to go to the 
depth of the focket: But as this will be at- 
tended with fome rifk of injuring the con- 
tiguous teeth by laying their roots bare, it 
ou^ht never to be advifed when with any 
propriety it can be avoided. 

After the operation a moderate degree 
of hemorrhagy is advifable, and ought to 
be encouraged with a view to prevent the 
fore from inflaming : But when it pro- 
ceeds too far, it mould be reflrained, by 
the patient taking from time to time a 
mouthful of fpirit of wine or of tincture 
of myrrh ; or if this does not prove fuf- 
ficient, the application of lunar cauflic 
will feldom or never fail. 

The fituation of the fore renders the 
application of dremngs inadmiflible : For 
fbme days, however, after the operation, 
the mouth fhould be frequently warned 
with a warm emollient decoction ; and af- 
terwards, if a cicatrix mould not form fo 
readily as might be expected, the cure may 
be promoted by the application of lime- 
water, 



v.$q> Difeafes of the Mouth. Ch.XXX, 

water, Port-wine, tincture of roles, or any? 
other mild aftringent. 



SECTION VII. 



Of Loose Teeth. 

npHE teeth ought naturally to continue 
firm till they become loofe by the or- 
dinary effects of old age : but they are 
liabfe to fome affections which render 
them loofe, and which even make them 
drop out at very early periods of life ; and 
as this is often productive of much diftrefs 
and deformity, it becomes frequently an 
important object with practitioners. 

As the teeth may become loofe from 
various caufes, all of which require a dif- 
ferent method of treatment, we mall enu- 
merate the moft material of them, and at 
the fame time mail point out thofe means 
pf cure which feem to be beft adapted for 
each of them. 

The 



Sea. VII. Dlfeafes of the Mouth, iji 

The teeth are frequently loofened by 
external violence : By falls and blows — 
and often by an improper ufe of inftru- 
ments in pulling the contiguous teeth when 
carious or other wife difeafed. 

Teeth loofened in this manner can be 
made faft only by being kept for fome 
time as firm as poffible in their fituation ; 
which may be done by preffing them as far 
into the fbeket as they will go, and fixing 
them with ligatures of Indian-weed, cat- 
gut, or waxed (ilk, to the contiguous teeth, 
and feeding the patient upon fpoon-meat 
till they become firm. 

In young people, when teeth are loofen- 
ed by external violence, as the fockets at 
this age are complete, they readily become, 
firm again when they are kept a due time 
in their fituation by ligatures : nay, even 
when they are forced entirely out of the 
fockets, they will foon become firm, if 
they be immediately replaced and retained 
in their fituation. I have in feveral in- 
itances put this method of treatment fuc- 

cefsfully 



232 Difeafis of the Mouth. Ch. XXX. 

cefsfully in practice, and no harm can re- 
fult from the trial. But in old age, when 
the teeth become loofe, from whatever 
caufe this may happen, the chance of their 
being again firmly fixed is very final 1; fo' 
that in very advanced periods of life the 
practice ought never perhaps to be attempt- 
ed. 

The teeth fometimes become loofe from 
thick layers of tartar forming upon them, 
and pafling in between the gums and the 
roots, and in fome cafes even between the 
lockets and the roots : In this cafe the re- 
moval of the caufe, if it has not fubfifted 
too long, will commonly be attended with 
a removal of the effect. The tartar fhould 
be completely fcaled off: but it ought to 
be done as foon as poflible ; for the longer 
the teeth remain loofe, the lefs chance there 
will be of their ever again becoming firm. 

We frequently find the teeth become 
loofe, from the gums becoming foft and 
fpongy, and feparating not only at their 
necks, but often a confiderable way down 

from 



Sect. VII. Dlfeafes of the Mouth, 233 

from the roots. This fometimes occurs 
from a long continued courfe of mercury; 
but it is commonly, although often impro- 
perly, attributed to the fcurvy. It no doubt 
occurs as a (ymptom in the real fea- fcurvy: 
but this is a very uncommon difeafe at 
land ; while the other, viz. a foft fpongy 
ftate of the gums, is frequently met with. 

When, however, it originates from a 
general fcorbutic affection of the fyftem, 
nothing but a removal of this will accom- 
plifh a cure ; but when it is a local difor- 
der merely, topical remedies are alone to 
be depended on. When teeth have re- 
mained long lbofe, we cannot with any 
certainty fay that any means we may em- 
ploy will render them firm; but the moil 
effectual remedy hitherto employed, is, 
fcarifying the gums both in the outfide 
and infide of the affected r eeth The in- 
cifions mould be carried deeply into the 
fubftance of the gums : the, flioald be al- 
lowed to difcharge freely, and ihould 
even be repeated from time to time as 
long as any of the teeth remain loofe. By 

Vol. IV. Q^ thia 



234 bifeafes of the Mouth. Ch. XXX. 

this means the full fpongy ftate of the 
gums we have defer ibed is often removed, 
and a difpofition produced in them to ad- 
here to the inverting membrane of the teeth, 
by which they often become perfectly firm. 
With a view to remove this fponginefs 
of the gums, aftringents are frequently pre- 
fcribed ; but I never knew any advantage 
refult from them : On the contrary, a fre- 
quent ufe of them feems to do harm, by 
inducing a difpofition in the gums, which 
deprives them for ever of the power of 
adhering to the parts beneath : at . lead, 
I have met with different inftances where 
this. appeared evidently to be the cafe ; in 
which, by a long continued ufe of reme- 
dies of this kind, the gums became fo hard 
and firm, that the fcarifications which were 
afterwards employed had no effec~l in fix- 
ing them. They mould not therefore be 
ufed till an adhefion is produced between 
the gums and the teeth, either by means 
of fcarifkatioas, or in fome other manner; 
and when this is acccmplifhed, they may 
be employed with freedom, and even with 

advantage. 



Sed. VIL Difeafes of the Mouth. 235 

advantage. The remedies of this kind that 
are to be mod depended on, are, tinctures 
of Peruvian bark, of oak bark, tindure of 
myrrh, and a ftrong folution of alum. 
The mouth mould be frequently warned 
with cold water, ftrongly impregnated 
with any of thefe, at the fame time that 
the patient mould be direded not to ufe 
thofe teeth that have been loofe till they 
have for fome time been perfectly firm. 

The teeth are fometimes loofened by the 
formation of abfcefTes between their roots 
and the alveoli ; efpecially when the alve- 
oli, from being thus immerfed in matter, 
at laft become carious: but having already 
treated minutely of this point when fpeak- 
ing of gum-boils, in the fourth fedion of 
this chapter,' we mutt now refer to what 
was then faid upon it. 

It is fcarcely neceffary to mention the 
loofening of the teeth which occurs in old 
age; for this takes place from a caufe for 
which there is no remedy. Not from the 
roots of the teeth decaying, or from their 
being pufhed out of their fockets, but from 



2^6 Difeafes of the Mouth. Ch.XXX, 

a real annihilation of the lockets; probably 
in confequence of the ofleous matter of 
which they are compofed being abforbed^ 
while nature having now no ufe for teeth» 
does not continue to fupply it. 



SECTION VIII. 



Of cleaning the Teeth. 

n^HE teeth are apt to become foul from 
different caufes, and frequently re- 
quire the a Alliance of a dentift to render 
them clean. 

i. They fometimei lofe their natural 
healthy colour, and acquire a dufky yel- 
low hue : Or they become to a certain de- 
gree black, without any adventitious mat- 
ter being perceptible on any part of them. 

2. On other occafions they become foul, 
and give a difagreeable putrid taint to the 
breath, merely from a too long remora of 
the natural mucus of the mouth. 

3. But 



If IjATC lvit 







Sect. VI'lI. Difeafcs of the Mouth. 237 

3. But the mod frequent caufe of foul 
teeth is a calcareous matter forming upon 
them commonly termed the Tartar of the 
Teeth, which feems to be a depofition from 
the faliva, as calculi in the bladder are from 
the urine. There are few people entirely- 
exempted from this ; but fome are much 
more liable to it than others, infomuch 
that 1 have known different inftances, of 
the teeth becoming thickly incruftated 
with it, in the courfe of a few weeks after 
they have been completely freed from it. 

The tartar firit appears in the fore-teeth, 
and in thofe parts of them that are leaft 
liable to be rubbed upon by the tongue or 
by the lips. Hence it is firft perceived on 
the outfide, in the angles between two of 
the teeth near to the junction of the gums. 
The ordinary effects of maftication pre- 
vents it in general from fpreading towards 
the points of the teeth: but the difpofition 
to form it is in fome conftitutions lo remark- 
able, that 1 have known it proceed from 
the gums upwards even over the flat 
iurfaces of the grinders j and in luch in- 
Qj$ (lances, 



238 Difeafes of the Mouth. Ch. XXX, 

fiances if it be not removed, it is apt to 
fpread over the whole teeth fo as to give 
the appearance of a continued incruftation 
from one end of the jaw to the other. In 
fome cafes again, inftead of paffing over the 
■whole, it feems to fix more particularly on 
one or two teeth; and in fuch inftanees 
the depofition of this matter goes on fb 
quickly as to give caufe to fufpect that the 
whole calcareous matter of the mouth is 
by fome caufe or other attracted to this 
particular point. I have known one or 
two teeth completely covered with it in the 
fpace of a few w eks, while the reft of the 
mouth has remained entirely free of it. 
In fome cafes thefe partial incruftations 
become fo large as to disfigure the cheek 
outwardly ; and, by thofe not accuftomed to 
this branch of practice, they are fometimes 
miftaken for difeafes of a more formidable 
nature. They have even been treated as 
exoftofes of the jaw bone. 

While the tartar confifts of a thin fcale 
only, and as long as it is confined to the 
external furface of the teeth, and does not 

prove 



Sett. VIII. Difcafes of the Mouth. 23$ 

prove hurtful to the gums, it feldom meets 
with much attention: but when it forms 
in any confiderable quantity, it very com- 
monly hurts the gums by producing flight 
ulcerations upon thofe parts to which it 
lies contiguous ; or, it infinuates itfelf be- 
tween the gums and the alveoli, fo as to 
feparate them to a confiderable depth from 
one another. In either of thefe events, 
thofe means (hould be employed by which 
we know that it will be mofl effectually 
removed. 

When the teeth have remained long co- 
vered with extraneous matter of any kind, 
if it has acquired any degree of firmnefs, 
it is fcarcely poflible to remove it without 
the affiftance of inftruments. Even a, flight 
difcolouring, although it may not be at- 
tended with any perceptible covering of an 
adventitious matter, if it is of long conti- 
nuance, it can feldom be removed in 
any other manner But when once the 
teeth are thoroughly cleaned with fcaling 
inftruments, they may in general be pre- 
served in this flate with a very ordi- 
Qjj. nary 



64& Difcnfes of the Mouth. Ch. XXX. 

nary degree of attention. Frequent warn- 
ing with cold water ; and rubbing them 
every fecond or third morning with burnt 
bread ; Peruvian bark ; cream of tartar ; 
chalk ; or any other mild application in fine 
powder, will for the moft part keep them 
perfectly clean and white : but this we 
mufl obferve is not univerfally the cafe j 
for the tendency we have mentioned to a 
foulness of the teeth, especially to a depo- 
fition of tartar, is in fome inftances fo great* 
that the greatefl pains and attention will 
not prevent the renewal of it. This, how- 
ever, is not a common occurrence ; for we 
all know, that a due attention to cleanli- 
nefs will very generally prevent every for- 
mation of this kind*. 

We have faid, that when once the teeth 
have become very foul, they cannot beclean- 
,ed without the affiftance of inftruments. 
This is at leaft the beft, as it is the fafeft 
method. It is necefTary however to obferve, 
that the application of acids of a certain 
ftrength will in general render the teeth per- 
fetUy clean, and even white j for the tartar 

and 



Se<5l. VIII. Dif cafes of the Mouth, 241 

and other matter chat adheres to them being 
foluble in acids, a frequent ufe of them will 
remove it completely ; and we according- 
ly find, that acids of one kind or another 
form the bans of almoft every waih that 
has been advertifed for the teeth. The 
public, however, ought to be much on 
their guard againft every application of 
this kind ; for the teeth themfelves are 
very apt to be hurt by acids, infomuch 
that it is perhaps impoflible to employ any 
remedy of this nature of a fufficient ftrength 
for diflblving any extraneous matter upon 
them, that will not at the fame time prove 
injurious to the enamel. Every one knows 
that even the mildeft vegetable acid will 
render the teeth rough, or fet them on 
edge : We may therefore very readily 
fuppofe, that thofc of a llronger nature, 
the mineral acids, which are very com- 
monly ufed for this purpofe, muft prove 
much more hurtful ; and in fact many 
have loft their teeth entirely by the ufe of 
applications of this kind. 

It is indeed faid by many, that inftru- 
jnents have done much harm, by hurting 

the 



242 Difeafes of the Mouth. Ch. XXX. 

the enamel of the teeth, at the fame time 
that they remove the incruftation with 
which they are covered. This 1 believe 
has happened in fome inftances : but it 
ought not to be considered as the fault of 
the remedy, but of the manner of applying 
it. A fharp inftrurnent may no doubt be 
£o improperly ufed as to remove the ena- 
mel entirely ; but this mufl always be the 
fault of the operator : for every incru- 
ftation to which the teeth are liable may be 
taken off with fafety, and without doing 
any injury whatever to any part of the 
teeth. 

In Plate LVIII. inftruments of various 
forms are reprefented for this operation. 
Figs 2. 3. and 4. are the beft, and will anfwer 
for mod purpofes ; but the others are fome- 
times neceffary for the removal of fuch 
parts of the incruftation as form between 
the teeth. They mould all be moderately 
fiiarp, otherwife the operation will be done 
with difficulty : but the edge of none of 
them ought to be fine, otherwife it will be 
apt to turn, and even to break, with the 
force neceffary for fcaling off the tartar. 

In 



PLATE IAI1I 




2. .*IG.| 3. 




8 . PIG . 



ne II io 



J* 



Sea. VIII. Difeafes of the Mouth. 243 

In performing this operation, the pa- 
tient fhould be placed upon a low feat, 
with his face oppofite to a clear light, and 
his head fupported by an affiftant. The 
furgeon himfelf fhould be feated'upon a 
chair fomewhat higher. It is commonly 
indeed done while the operator is {land- 
ing ; but we have elfewhere had occafion 
to remark, that practitioners ought to fit 
at every operation when it can be done 
with propriety. 

The furgeon fhould now wrap the fore- 
finger of his left hand in a wet cloth, with 
which he is to prefs with fome firmnefs 
upon the point of the tooth intended to be 
firft cleaned, while the back part of the 
fcaling inftrument will form a point of 
refiftance for the thumb of the fame hand. 
In this manner the tooth may be firmly 
fupported fo as to prevent every rifk of 
its being moved or loofened by the inftru- 
ment. This in every cafe is a necefTary 
precaution ; but it is particularly fo when 
the teeth are in any degree loofe. 

The fharp edge of the inftrument is now 

to 



244 Difeafes of the Mouth. Ch. XXX. 

to be insinuated beneath the under part of 
the incruftation, care being at the fame 
time taken to avoid the neck of the tooth, 
otherwife, if it be puftied down this length, 
and if much force be employed, there will 
be much rifk of loofening, or even of turn- 
ing out, the tooth entirely. On being cer- 
tain that the inftrument is properly pla- 
ced, it mud be pufhed with fome firmnefs 
from below upwards to the top of the 
tooch, and muft be repeatedly applied in 
the fame direction as long as any of the 
incruftation remains either on the outfide 
or infide of the tooth : And one tooth be- 
ing completely cleaned, all the reft which 
require it muft be treated in the fame man- 
ner. This being done, the teeth mould 
all be well rubbed over with a bit of 
fponge in the form of a brum, covered 
with a fine powder prepared of equal parts 
of cream of tartar and Peruvian bark ; and 
this being continued from time to time, it 
■will feldom happen that any farther affift- 
ance will be neceflary : but if, notwith- 
flanding of this, the teeth are again ob- 

ferved 



Se&.VIII. Difeafes of the Mouth. 245 

fcrved to turn foul, any incruftation that 
may form upon them muft be fcaled off 
in the manner we have mentioned. 

This is the fafeft and moft effectual me- 
thod of cleaning the teeth when they be- 
come foul from any kind of extraneous 
matter forming upon them; but they fome- 
times lofe their colour, as we have already 
obferved, and acquire a kind of foulnefs, 
when no matter of this kind is perceptible. 
Even in fuch cafes, as long as the furface 
of the teeth remains fmootfi and found, 
moderate friction with the edge of a fca- 
ling inflrument will frequently prove fer- 
riceablc: and if the operation be done 
with caution, no rifk whatever will accrue 
from it. But when the teeth become black 
from acaufe of this nature, we fomenmes 
find the enamel corroded, or perforated as 
it were with an infinite number of fmall 
holes ; and this, we muft obferve, is the 
word kind of foulnefs to which they are 
liable : for it is difficult to remove, and 
when removed, it in general foon returns, 

and 



t$6 Difeafcs of the Mouth. Ch. XXX. 

and feldom flops till all the teeth which 
have been attacked with it are deflroyed. 

As this kind of foulnefs cannot be re- 
moved with inltruments, we are under the 
neceffity of employing fume chemical pre- 
paration for difTolving it. All the mine- 
ral acids will do this in the mofl effectual 
manner ; bur, for the reafons we have al- 
ready given, they ought never to be ufed. 
I have commonly employed faponaceous, 
or even pure alkaline applications ; by 
which the tqeth may be often rendered 
perfectly clean without any injury being 
done to the enamel. A flrong lather 
of common foap will often anfwer ; and 
a folution of fait of tartar applied over 
the teeth with a fmall pencil or brufh, 
will on fome occafions prove equally fuc- 
cefsful. 

When in this manner the foulnefs is re- 
moved, frequent warning with cold water, 
and rubbing from time to time with one 
of the powders above mentioned, are the 
mofl effectual means for preventing a re- 
turn of it. I have fometimes thought too, 

that 



Scd. VIII. Lifeafcs of the Mouth. 247 

that repeated applications of tincture of 
Peruvian bark have proved ferviceable in 
preventing it. Indeed, as this variety of 
the affection feems to depend upon fome 
caufe of a putrefcent nature ; for it is evi- 
dently attended with a caries or mortifi- 
cation of the affected teeth ; there is reafon 
to fuppofe that antifeptics of every kind 
may prove ufeful in the treatment of it. 

For the purpofe of applying powders 
and other applications to the teeth, brufhes 
of different forms, and various kinds of 
roots properly prepared, are daily ufed. 
Lucerne and alkanet roots dried and beat at 
one end, into the form of a bruih, are much 
employed for this purpofe, and they may 
be ufed both -with fafety and advantage for 
cleaning the interflices between the teeth : 
but neither thefe nor any kind of brufh 
fhould be employed for rubbing the roots 
of the teeth and the upper parts of the 
gum ; for as their points pafs in between 
the gums and the fockets, they are apt 
to feparate the one from the other, from 
which much mifchief is apt to enfue. 

For 



«48 Difeafes of the Mouth. Ch.XXX. 

For this reafon, I always employ a piece of 
fponge fixed in a fmall handle, with wjiich 
the roots of the teeth may be rubbed with 
fafety. 



SECTION IX. 



Of ToOTHACH. 

r T" , OoTHACH appears to be more unfup- 
portable than any other kind of pain. 
It renders thofe who are affected with it 
very unhappy ; and as it is one of the moft 
frequent difeafes to which the human bo- 
dy is liable, it requires much attention 
from practitioners. The pain induced by 
toothach, even when it is confined to afingle 
tooth, is often productive of great diflrefs ; 
but this is trifling when compared with 
the confequences which fometimes enfue 
from it. Indeed many inftances have oc- 
curred of the ftrongeft conftitutions being 
ruined by frequent returns of it. Befides 

the 



Sea. IX. Dlfcafes of the Mouth. 249 

the ufual fymptoms of pain in one or more 
of the teeth, and of fwelling in the conti- 
guous gums ; the cheek frequently be- 
comes tumefied ; the eye, and even the ear 
of the affected fide, are often attacked with 
pain and inflammation ; and to thefe, fe- 
ver, with all its confequences, is apt to 
fucceed. 

Thefe fymptoms may be induced by^ 
different caufes, and by affections of the 
teeth feemingly of oppofite natures. 

1. They may originate from the nerve 
and other parts within the cavity of a 
tooth being denuded, either by external 
violence, or by the enamel falling off in 
confequence of becoming carious or other- 
wife difeafed. 

2. They may proceed from inflamma- 
tion, either of the parts within the affected 
tooth, or of the membrane which furrounds 
the root of it. And, 

3. The teeth and contiguous parts of 
the jaws are often attacked with very 
violent pain in confequence of what is 
ufually termed Sympathy j that is, they 

Vol. IV. R often 



250 Difeafes of the Mouth. Ch.XXX. 

often become pained from affections of 
diftant parts, very fevere fits of toothach 
being fometimes induced by difeafes of 
the eye, of the ear, and of the fhomach. 
We fhall proceed to treat feparately of 
thefe caufes in the order they are here 
mentioned. 

§ j. 0/ Toothach from the Nerve being laid bare, 
and of the Various Methods of Extracting 
Teeth. 

In whatever manner the cavity of a 
tooth be expofed, we find from daily ob- 
fervation, that for the moft part it is pro- 
ductive of much pain ; and the reafon is 
obvious. Nature, as we have already ob- 
fei ved, has provided the teeth with nerves, 
bat at the fame time (he has given them 
a very complete covering of bone : When 
this protection, therefore, is deflroyed, 
either by accident or difeafe, it muft ne- 
ceiTarily follow, that thefe parts which 
were not formed for being expofed, will 
fufFer various injuries, not merely from 
the food and drink finding accefs to them, 

but 



Sect. IX. Difeafes of the Month. 251 

but from the external air being at all times 
freely applied to them. 

But it is not the mere expofure of 
a nerve, or the violence employed in 
laying it bare, which produces pain j it 
is the confequence of this expofure, the 
effects which refult from it, to which all 
the diftrefs which enfues ought to be at- 
tributed : Of this every practitioner mufl 
have met with frequent inftances. Thus 
I have often known the cavity of a tooth 
laid entirely open by a tooth being broke 
by a fall or a blow, and no inconvenience 
enfue from it but a temporary pain fome- 
what proportioned to the nature of the 
accident ; and it frequently happens that 
teeth begin to fpoil .and at laft moulder 
away without any pain or uneafinefs. It 
is therefore evident, that expofure of the 
nerve alone is not to be confrdered as the 
ultimate caufe of toothach. It is a certain 
degree of irritability induced by this expo- 
fure which appears to be the caufe of it ; 
and to this our views ought to be directed 
in the treatment of it. 

Ra " This 



252 Difeafes of the Mouth. Ch. XXX. 

This irritable ftate of the nerve may be 
induced by various caufes, and more efpe- 
cially by faccharine, acid, and other fti- 
mulating fubftances contained in food, be- 
ing frequency applied to it; — by a too 
frequent ufc of toothpicks, which may 
often be traced as the origin of a fit of the 
toothach ; — and by much expofure to a 
ftream of cold air. Expofure to cold, 
particularly in a damp ftate of the air, 
often terminates in toothach by inducing 
inflammation ; but it frequently produces 
very viol nt degrees of pain in a tooth al- 
ready deprived of part of ics enamel, when 
no other fymptom of inflammation can be 
difcovertd. 

Thefe are the moft common caufes of 
toothach when the nerve of a tooth has 
previoufly been laid bare ; and in fuch 
circumstances their mode of operating 
mav be eafily accounted for ; but we can- 
not fo eafily explain or fuggeft a reafon 
for this ftate of a tooth being fuch a fre- 
quent occurrence, nor does it appear in 
what manner it is for the moft part pro- 
duced. 



Sect. IX. Dlfeafcs of the Mouth, 253 

duced. The enamel is fometimes broke 
by falls and blows, and it frequently 
fuffers by attempts to break nuts and 
other hard fubflances with the teeth : In 
fuch cafes the caufe is obvious ; for we 
know by daily obfervation, that rhe ofleous 
part of a tooth very foon becomes carious 
and waftes away on the enamel being de- 
flroyed. But how do we account, for the 
moft frequent of all caufes of toothach, 
the decay or wafting of the enamel by 
rottennefs, when no evident external vio- 
lence has been applied to it ? It has been 
alleged that we may often trace it to a too 
free ufe of acids, which are generally 
known to prove hurtful to the enamel ; 
and by fome it is faid that it depends mod 
frequently upon a want of cleanlinefs in 
not warning or otherwife clearing the 
mouth of putrefcent particles after meals. 
Particles of this kind by reding upon the 
teeth are fuppofed to be capable of com- 
municating fome degree of their own na- 
ture to the enamel ; and the affection be- 
ing once produced in a fingle point, the 
R 3 cou~ 



254 Difeafes of the Mouth. Ch. XXX. 

contiguous parts will become difeafed, wq 
are told, from the fame caufe that mortifi- 
cation fpreads in other parts of the body. 
We will readily admit that a frequent 
application of acids to the teeth, even thofe 
of the mildeft nature, will, prove hurtful 
to the enamel ; and therefore they fhould 
be avoided ; while it is equally clear, that 
the mouth mould be regularly wafhed af- 
ter meals, not only for preventing that 
kind of incruftation upon the teeth which 
we have already confidered, but for pre- 
ferving a fweetnefs of breath : It does not 
however appear probable, that the difeafe 
of which we are now treating, fpoiled or 
carious teeth, depends upon either of thefe 
caufes. Were it to originate from a too 
free ufe of acids, it ought to affect all the 
teeth, or at lead a confiderable part of them, 
at the fame time and in an equal degree ; 
whereas it begins almoft in every inftance 
in a very fmall point or fpot, which in 
general extends much more ilowly than it 
probably would do if the difeafe proceed- 
ed from any caufe of this nature. And 

again, 



Se&. IX. Difeafes of the Mouth. 255 

again, with refpect to the effect of any pu- 
trefcent particles lodging upon the teeth, 
we do not think it probable that this dif- 
eafe can be ever induced by them. A piece 
of meat remaining in the mouth from one 
meal to another, may acquire fome degree 
of fetor ; but it cannot probably in that 
ihort period become fo highly putrid as 
to deftroy the living piinciple in thofe 
parts with which it comes into contact. 
It is a point, however, which may be ea- 
fily determined by experiment ; and from, 
the refult of fome trials which I made for 
this purpofe, there is reafon to fuppofe 
that the common opinion with refpect to 
it is ill-founded. A tooth newly pulled 
was put into the centre of a piece of pu- 
trid beef, and after remaining in it for 
eight days, it was as free from putrefaction, 
as when firft put into it, neither the ena- 
mel nor internal parts of the tooth being 
in any degree affected ; and the experi- 
ment being repeated with teeth which had 
been pulled for a confiderable time, the 
refblt was exactly fimilar. Now, if this 
R 4 hap- 



256 Difeafes of the Mouth. Ch. XXX. 

happens with teeth entirely dead, even 
when totally immerfed in highly putrid 
matter, we may fairly conclude, that a par- 
tial application of putrefcent particles to 
teeth (till enjoying life and connected with 
the reft of the body, will not probably 
have much effect : for we know, that in 
other parts of the body the vital principle 
has a confiderable effect in refitting putre- 
faction ; and there is no reafon to doubt 
of the teeth being endowed with the fame 
power of felf-prefervation. But, befides 
this general argument in fupport of our 
opinion, we may remark, that if the com- 
mon idea on this point was well founded, 
thofe parts of the teeth mould be moft 
liable co corruption where particles of 
food are moft apt to lodge ; while, on the 
contrary, thofe parts of them which are 
ivt expoied to this, fhould feldom or ne- 
ver fuffer. Now every practitioner knows 
that this is by no means the cafe ; for it 
mult be acknowledged, that one part of a 
100th is juft as apt to become carious as 
another. The moft likely part for food 



Sect. IX. Bifeafes of the Mouth. 257 

to reft in is between two teeth ; and we 
allow that the teeth fometimes fpoil in 
thefe parts, but by no means more fre- 
quently than in other parts not fo much 
expofed to this inconvenience. 

It does not appear, therefore, that the 
caufes ufually fuppofed to be moft pro- 
ductive of carious teeth have much effect, 
nor do we know of any incidental occur- 
rence to which in particular this affection 
can be attributed : From all the obferva- 
tion I have been able to make upon it, I 
think we ought rather to confider it as 
depending for the moft part upon fome 
general conftitutional caufe ; upon fome 
tendency in the fyftem to produce a waft- 
ing or decay of this particular part. The 
caufe of this again 1 fhall not pretend to 
explain ; but 1 think it perhaps equally 
probable that this rotting of the teeth we 
are now conlidering, depends upon fome 
general affection of the fyftem, as that pain 
in the gout originates from fome general 
caufe. Inftances no doubt occur, of teeth 
becoming carious evidently from fome 

parti- 



25B Difeafes of the Mouth. Ch. XXX. 

particular occafional caufe, and efpecially 
from externa] violence breaking or crack- 
ing the enamel. This, however, is not 
a common occurrence : indeed it is very 
rarely met with when compared with 
the frequency of carious teeth ; a difeafe 
which in mod inftances begins without 
any evident caufe, and which in general 
has fubfifted for fome time before being 
noticed. 

But allowing that the opinion we have 
offered upon this point were admitted, 
it may be afked, To what purpofe will 
it tend ? Will it fuggefl any differ- 
ence in the treatment of the diforder ? I 
think it will. — As the pain of the tooth- 
ach creates much impatience, and is with 
difficulty fubmitted to, if the affected tooth 
is carious, it is in general not only the de- 
fire of the patient, but the earneft advice 
of practitioners, to have it extracted, as be- 
ing the moft certain means of obtaining 
relief. In violent degrees of toothach, 
when the other remedies ufually employed 
are found to fail, extraction of the difea- 



Sect. IX. Difeafes of the Mouth. 259 

fed tooth ought certainly to be advifed ; 
and in fuch circumftances no perfon can 
be more clearly of this opinion than I am; 
but I am equally cl?ar, that, in common 
practice, this is carried too far, and that 
many teeth are pulled daily which ought 
not to be touched. In moft inftances, the 
pain will be removed immediately on the 
difeafed tooth being extracted : but it very 
commonly happens that relief thus ob- 
tained is only temporary, and that the ca- 
ries foon fixes upon fome other tooth, 
which in a fhort time becomes as much 
difeafed as the firft ; and this being like- 
wife removed, the diforder often proceeds 
from one to another, till fcarcely any are 
left. I have met with various inftances of* 
this, where almoft the whole teeth have 
been fuccefsfully taken out, one becoming 
carious foon after the removal of another. 
Nor is there even at lafl any advantage 
gained by the practice; for, after all the 
teeth are taken out, the pain in many cafes 
remains equally fevere in the jaw itfelf. 
The frequent occurrence of cafes of this 

kind 



$6o Difeafes of the Mouth. Ch. XXX. 

kind tends much to eftablifh the opinion 
of carious teeth being often a cOnflitutional 
difeafe; and it like wife fuggefts the pro- 
priety of lefs frequ«it extraction than 
what in common practice is found to pre- 
vail. As we can never at firft be certain 
whether the diforder depends upon a ge- 
neral caufe of this nature or not, it is per- 
haps right in every cafe to extract the firft, 
and even the fecond tooth that becomes 
affected, as foon as the violence of pain 
renders it necefTary : but whenever the 
difpofition is fo ftrongly fixed in the ha- 
bit that a third or a fourth are Jonn ob- 
ferved to be difeafed, the patient mould 
be always advifed rather to fubmit to a 
good deal of diftrefs than to extract any 
more: and it often happens, when he has 
refolution to fubmit to one fit of the tooth- 
ach, and to wait till it is completely over, 
that he never afterwards, in this tooth at 
leaft, feels any return of it. Cafes no doubt 
occur in which this does not fucceed; but 
it anfwers often enough to warrant the pro- 
priety of giving it a fair trial in perhaps 

every 



Sed. IX. Difeafes of the Mouth. 261 

every inftance : Even where it fails, there is 
no harm done by the trial j and when it is ' 
found to fucceed, the advantage gained by- 
it is great indeed. For a confiderable time 
I adopted the common practice on this point 
in its full extent : Every carious tooth at- 
tended with pain I advifed to be pulled ; 
but rinding in general that no advan- 
tage was derived from it, the refult being 
for the moft part nearly as I have already 
defcribed, 1 was hence induced to attempt 
a different method ; and now after a pa- 
tient has had two or three teeth extracted, if 
the difeafe flill continues to return, I never 
advife the practice to be pufhed farther, 
unlefs when the pain is fo very fevere as 
to render it abfolutely neceflary, which is 
not however often the cafe. By avoiding 
expofure to cold during the fit, and by 
exhibiting dofes of laudanum proportion- , 
ed to the degree of pain, the diftrefs pro- 
duced by it is at lafh in general removed ; 
and by due attention to cleanlinefs, parti- 
cularly by frequently warning the mouth 
with cold water, and, when practicable, 

by 



2^2 Difeafes of the Mouth. Ch. XXX, 

by fluffing the opening in the carious 
tooth £o as to prevent the air from find- 
ing accefs to it, many have been faved, not 
only from the pain aad diftrefs of pulling 
thefe teeth which became firfl affected, but 
of lofing others, which in all probability 
would have become carious if the com- 
mon practice had been followed of ex- 
tracting every difeafed tooth as foon as it 
becomes in any degree painful. 

Having thus endeavoured to fhow that 
carious or fpoiled teeth are moll frequently 
produced by fome general constitutional 
eaufe, we fhall now proceed to confider 
more particularly the means to be em- 
ployed, not only for preventing, but for 
removing toothach depending upon this 
caufe. 

In cafes of carious teeth, itJias been a 
prevailing practice to advife the black or 
mortified fpot to be removed with a file, 
with a view to prevent the difeafe from 
fpreading ; but, fo far as my obfervation 
goes, it ought not to be adopted ; for the 
difeafed part of a tooth can never be re- 

•moved 



Sea. IX. Difeafes of the Mouth. 263 

moved without expofing thofe parts which 
remain to a more free accefs of air than 
they were previoufly liable to ; and there- 
fore, inftead of proving ufeful, I have al- 
moftuniverfally feen it do harm. In many 
inftances, I have known it induce pain 
where there was none before; and inftead 
of preferving a tooth, it frequently feems 
to have the effect of .rendering the remain- 
ing found parts fooner carious than they 
would probably have become if they had 
not been touched. I am therefore clear, 
that this practice of filing mould be laid 
altogether afide ; and whoever contiders 
the neceiTary effect of it will probably be 
of the fame opinion. It is evident that 
the part of a tooth already carious cannot 
be feniible of pain. For what purpofe, 
therefore, mould we remove it ? While it 
remains, it ferves in fome degree to cover 
and protect the found parts beneath, while 
by taking it off they are left perfectly bare, 
and apt to be hurt by whatever is taken 
into the mouth. 

When, again, as much of the enamel is 

removed, 



26*4 ' Dlfeafes of the Mouth. Ch. XXX. 

removed, either by caries or external vio- 
lence, as to form a hollow of any magni- 
tude, we have it frequently in our power 
to prevent an acceflion of toothach, by 
fluffing or flopping up the opening, fo as 
to prevent the air and particles of food 
from getting accefs to the nerve. Differ- 
ent fubflances are made ufe of for this 
purpofe: fuch as gum lac, maflich, oliba- 
nuin, bees- wax, and fealing wax, tin, lead, 
and gold. When the opening made by the 
difeafe is large, and efpecially when it is 
narrow at the bottom, and wider outwardly, 
maflich and gum lac, or even a bit of bees- 
wax, will fometimes anfwer when none of 
the harder fubflances will remain in the ca- 
vity: but as they are quickly rubbed down 
in maflication, they require to be frequent- 
ly renewed ; fb that fome of the metals are 
preferable when the form of the opening 
admits of their being employed, which is 
always the cafe when the tooth is much 
fcooped out inwardly, with a fmall hole 
leading into it. Gold leaf is fometimes 
ufed for this purpofe j but nothing an- 

fwers 



Sea. IX. Difeafes of the Mouth. 265 

fwers fo well as common tin-foil. As 
much of it mould be cut off as it is imagi- 
ned will be needed ; and one end of it be- 
ing pufhed into the hollow of the tooth with 
the inftruments, fig. 6. 7. or 8. Plate LVlIf. 
the reft of it mould be gradually preffed in 
till the cavity is completely filled : and this 
being done, any portion of the tin that 
may be left mould be cut off, when the 
furface of the whole fliould be made 
perfectly fmooth by frequent rubbing 
with the burnifher, fig. 9. of the fame 
plate. But before any attempt: is made 
for (topping a tooth, the nerve fliould be 
rendered as infenfible as pothble ; for till 
this is accompli (lied, the patient will not 
be able to bear that degree of preffure 
which fixing the tin requires. In general 
the nerve becomes fufficient-v callous for 
admitting of this, mereh h\ rhe delay of 
a few weeks from its being; firfl laid bare: 
but when this does not prove effectual, we 
may often accomplifh our intention by in- 
ferring daily into the cavity of the tooth 
a few drops of oil of origanum or of thyme, 
Vol. IV. S or 



266 Difeafes of the Mouth. Ch. XXX. 

or any other efTential oil ; by which any 
flight degree of irritability in the nerve 
may be ofVn removed, fo as to admit of 
prefTure being applied to it with freedom. 
We have already obferved, that neither 
tin, lead, nor any hard fubftance, will re- 
main in the hollow of a tooth unlefs the 
opening into it be fomewhat contracted. 
It has been propofed, however, when the 
opening is of a different form, and when 
the fluffing cannot be fixed in any other 
manner, to do it by drilling a fmall hole 
through the fides of the tooth ; fo that 
when the lead is prefTed into it, it may be 
retained by pafhng a peg of fiber, gold, or 
any other metal, from one fide of the tooth 
to the other. In a few cafes this may fuc- 
ceed ; but it will not anfwer either where 
the opening is very wide outwardly, or 
where the fides of the tooth are not tole- 
rably firm j for where the external open- 
ing is very wide, even a peg pafTed through 
the centre of the fluffing will not keep it 
fufficiently firm to prevent fome parts of 
the food from finding accefs beneath it ; 

and j 



Sea. IX. Difeafis of the Mouth. 267 

and, when the remaining parr of the tooth 
is become thin and brittle, it will be apt to 
break by the means employed for making 
the hole. ' 

When, however, by any of the means 
we have mentioned, the hollow of a tooth 
can be properly (topped, it will not only 
prove the molt effectual method of pre- 
venting frequent returns of toothach, but 
will have fome influence in preferving 
the remaining part of the tooth. I have 
known various inftances of this where 
fpoiled teeth have been preferved for a 
great number of years, without being pro- 
ductive either of pain or any other in- 
convenience ; but this requires the cavity 
to be very completely (topped, fo as td 
prevenf every poflibility of accefs either to 
food or drink, or even to air. 

When a patient with fpoiled teeth ha9 
been liable to frtquent fits of toothach, 
befides (tufHng them in the manner we 
have mentioned, he fhould be as attentive 
as poflible to avoid much expofure to colds 
His head mould be kept warm by proper 
S 2 coverings 



268 Difeafet of the Mouth. Ch. XXX. 

coverings through the night ; and he 
fhould live in a dry fituation. Indeed, a 
moift atmofphere proves fo deftructive to 
the teeth, that people who live in wet fi- 
tuations find it very difficult to preferve 
them ; and I have known various inftan- 
ces of frequent returns of toothach being 
prevented entirely, by the patient's remo- 
ving from a damp to a dry fituation : Nay 
this will fometimes fucceed when every 
other means have failed. 

By due attention to the means we have 
mentioned, much may be done in prevent- 
ing people with carious teeth from fuffer- 
ing fo much as they other wife would do : 
but, notwithftanding all our endeavours, 
teeth in this fituation are very apt to be- 
come painful, and are often productive of 
much mifery ; fo that the moll effectual 
method of removing it becomes a very im- 
portant objedl. 

There are fome varieties of toothach 
which we know from experience may be 
removed by remedies applied to diftant 
parts of the body. Thus when pain oc- 
curs 



Sect. IX. Dtfeafes of the Mouth. 26*9 

Curs in a tooth, as it fometimes does, from 
inflammation which firft began in the ear, 
it may be more effectually removed by ap- 
plying a blifter behind the ear than by 
any other means : Or when a foulnefs of 
the ftomach is the caufe of it, a vomit will 
prove the moft effectual remedy. 1 his we 
fhall afterwards confider in a more parti- 
cular manner. But when toothach pro- 
ceeds from the nerve of a tooth being laid 
bare, it will feldom happen that any appli- 
cation will prove ufeful that is not made 
directly to the part itfelf. Bark, electri- 
city, and a variety of noftrums, are fre- 
quently employed ; but in this variety of 
toothach, the only remedies I have ever 
known any advantage derived from, are, 
anodynes, corrofive applications, and ex- 
traction of the tooth. 

In flight degrees of toothach, the pain 
is fometimes relieved, or even altogether 
removed, by applying either opium or 
laudanum directly to the bare nerve : [ 
have known camphor too prove ufeful, 
bath, by itfelf and when conjoined with 
8 3 opium; 



%jo Difeafes of the Mouth. Ch. XXX* 

opium ; and it fometimes anfwers in a li- 
quid form, when difTolved in fpirit of 
wine, when it will not fucceed in any- 
other way ; Ether mav like wife be men- 
tioned as a remedy which in this kind of 
tooth ach fometimes affords relief; but as 
thefe and other applications of a milder 
nature do not commonly fucceed, we are 
for the mod part obliged to employ others 
of a more acfhve kind, with a view to de- 
stroy the nerve entirely, 

A long continued ufe of any of the 
ftrong effential oils will in fdme cafes, as 
we have already obierved, render the nerve 
callous or fomewhat infenfible, but they 
will never deftroy it fo effectually as to 
prevent the rifk of future returns of tooth- 
ach. This, however, may be done by re- 
medies of a different kind ; by the appli- 
cation of fpirit of vitriol or any other con- 
centrated mineral acid ; by inferting a bit 
of lunar cauftic into the cavity of the 
tooth ; or by burning the nerve with the 
aclual cautery. But, in ufing either the 
lunar cauilic or any of the ftrong acids, 

jxnuch 



Seta. IX. Difeafes of the Mouth. 271 

much attention is neceflary to prevent the 
contiguous parts from being hurt ; for 
if they be not inferted with much cau- 
tion, they are apt to fpread and to do a 
great deal of mifchief. The actual cau- 
tery may, however, be employed without 
any rifle of this kind : but in order to de- 
rive any real advantage from it, the hot 
iron muft be pufhed farther into the hol- 
low of the tooth than patients in general 
will allow ; for if the nerve be not destroy- 
ed to the very extremity of the root, no 
advantage will be gained ; and this being 
both tedious and painful, we do not find 
*many that will admit of it ; but when 
a proper application of it is agreed to, 
we may dettroy the nerve completely. It 
may be done with a piece of fmall wire 
made fharp at the point, or the inllrument 
reprefented in Plate LVII1. fig. 8. may be 
employed for it. 

It often happens, however, that none of 
thefe remedies prove effectual, either from 
patients not fubmitting to a due amplica- 
tion of them, or from practitioners not 
S 4 pufhmg 



272 Difeafes of the Mouth. Ch. XXX. 

pu fbing them €0 Tar as they ought to do. 
In this cafe, when the pain continues vio- 
lent, we are under the neceflity of de~ 
ftroying the nerve in a different manner, 
namely, by the extraction of the tooth ; 
and this being done, if the tooth be not? 
much fpoiled, and if it be not broke in the 
operation, after the focket is properly clear- 
ed of blood, it may be replaced in the 
manner we mall afterwards mention when 
treating of the method of tranfplanting 
teeth. This will not always fucceed, efpe- 
cially in the molares ; but in the back part 
of the mouth it is not fo neceffary as when 
the inciibres or canine teeth are taken out, 
when it will often anfwer : and when a 
tooth thus replaced becomes firm, it will 
prove equally ufeful as before ; while, 
from the total deftru&ion of the nerve, it 
will not afterwards be apt to produce pain. 
We fhall now proceed to confider the me- 
thod of extracting teeth. 

As the pulling of teeth is a very fre- 
quent operation, much pains has been 
taken to render it as eafy as poffible ; and 

although 



Sect. IX. Difeafes of the Mouth. 273 

although it is ftill necefTarily attended 
with pain, yet it is now performed both 
with more eafe and fafety than it could 
poffibly be in former times, while the in- 
ftruments employed for it were rude and 
unmanageable. 

It is evident that a tooth may be pulled 
in different directions : It may either be 
pulled in a perpendicular direction with 
refpect to its roots ; or _it may be made 
to turn upon its axis by deprefling the 
corona or upper part of it, by which 
the point of the root will be proportion- 
ally raifed ; or a fufficient degree of force 
may be applied for pufhing it out of the 
focket in a lateral direction. 

If thefe methods of operating were all 
equally practicable, we would not hefitate 
in determining to which the preference 
mould be given. In railing a tooth per- 
pendicularly, it is clear that much lefs 
violence muft be done to the contiguous 
parts than by forcing it out in a lateral di- 
rection : for as the roots of the teeth are all 
firmly fixed in bone, they cannot pombly 
be prefled out laterally, but with fuch a 

force 



bjr4 Difeafes of the Mouth. Ch. XXX.. 

force as is fufficientfor breakingorburfting 
open that part of the alveolar procefs of 
the jaw-bone with which they are fur- 
rounded ; and as this is in general attend- 
ed with fome laceration, and always with 
much contufion, of the contiguous fofc 
parts, it is neceffarily productive of a good 
deal of pain : but as all the fpace we can 
obtain, even by the greateft widenefs of 
the mouth, will not admit proper inftru- 
ments for moving the teeth in the back 
part of xh€ mouth in a perpendicular 
direction, we are for the molt, part under 
the neceflity of ufing fuch as move them 
laterally. All the incifores and canine 
teeth may indeed be taken out in this 
manner, and even fome of the molares, 
when they are very loofe j but when the 
molares are firmly fixed, no inftruments 
with which we are acquainted will pull 
them in this direction. Various propofals 
have been made for this purpofe ; but al- 
though hitherto every attempt of this kind 
has failed, fome farther trials may perhaps 
render our inftruments fufficiently perfect 
for effecting it. 

The 



Sed. IX. Difeafes of the Mouth. 27/ 

The only inftruments which practition- 
ers in former times were poflefTed of for 
the extraction of teeth, were different kinds 
of forceps or tenets, named according to 
their forms, Hawks-bills, Cranes- bills, &c. 
and different kinds of levers both ftraight 
and crooked. Thefe, however, were rude- 
ly conftructed, and it was with much dif- 
ficulty that teeth firmly fixed were moved 
by them. In procefs of time, therefore, 
various improvements were propofed on 
them ; but few of thefe being of much 
importance, we do not think it neceflary 
either to defcribe them, or to give deline- 
ations of them ; and this efpecially as 
they may be feen in the works of Garen- 
geot, Scultetus, Hildanus, and other wri- 
ters of the laft and preceding centuries. 
All that we mean to do, is to delineate 
thofe inflruments which are approved of 
by modern practitioners of reputation ; to 
propofe fuch improvements upon thefe as 
by experience have been found to prove 
■ufeful ; and to give a detail of the method 
of ufing them. 

For 



276 Difeafes of the Mouth. Ch.XXX. 

For a confiderable time part 1 , an inftru- 
ment termed a Key has been almoft the 
cnly one employed in Britain for extract- 
ing firm teeth, and it is now very generally 
ufed in different parts of the Continent. It 
is delineated in Plate L1X. fig. 1. and 2. 

In operating with this inftrument, if 
the tooth to be taken out is in the lower 
jaw, the patient mould be feated /m a 
chair, oppofite to a clear light, while his 
head fhould be fupported by an ailiftant 
(landing behind j but if it be in the upper 
jaw, he Ihould be feated upon a pillow, 
with his head turned back, and fupported 
upon the knees of the operator, who in 
this cafe muft ftand behind him, whether 
the tooth be in the right or left fide of 
the jaw : but when a tooth is to be ex- 
tracted from the lower jaw, if it be on 
the right fide, the operator fhould be pla- 
ced fomewhat to the left ; and, vice verfa, 
when the tooth is on the left fide, the fur- 
geon mould place himfelf fomewhat to the 
oppofite fide. With a view to admit of as 
free an application of the inftrument as 

pof- 



PLAT I''. I.l\ 





Sea. IX. Difeafes of the Mouth. 277 

po{Tible,as well as to prevent the gums from 
being lacerated, all the foft parts adhering 
to the teeth ihould be flowly and cauti- 
oufly feparated from it by infinuating be- 
tween them the point of the fcarificator, 
fig. 1. Plate L. j and this being done, the 
operator mull proceed to the application 
and ufe of the key. The patient having 
cleared his mouth of blood, the point of 
the claw C, Plate LIX. fig. 1. muft be 
prefTed as far down between the gum and 
the tooth as poflible ; and in this fituatioa 
it muft be firmly fixed and retained by 
the fore-finger of the left-hand, while the 
fulcrum Z), being placed as far down as it 
will go upon the gums on the opposite fide 
of the tooth, the operator muft now with 
his right-hand apply fuch a force as he may 
find necefTary for moving it j and by turn- 
ing the hand fufficiently round, almoft any 
tooth may be taken out at one pull with- 
out railing the inftrument : but whenever 
a tooth is found to be very firmly fixed, 
and efpecially if it be one of the large mo- 
lares whofe roots diverge confiderably, it 

is 



278 Dlfeafes of the Mouth. Ch. XXX. 

is better, after it is freely loofened, to re- 
move the inflrument ; and having turned 
the claw to the oppofite fide, to apply it fo 
as to turn the tooth to the other fide of 
the jaw, by which it will be rendered fo 
completely loofe as to be eafily taken out 
with the common teeth forceps, Plate LXI. 

In ufing the key-inftrument, when the 
tooth to be taken out is firmly nxed, and 
efpecially when there is little or no vacant 
fpace between it and the contiguous teeth, 
fome attention isneceflary to prevent thefe 
from being loofened. When it cannot be 
prevented in any other manner, the edges 
of the tooth to be removed fhould be filed 
down with a very thin file, which may be 
done without hurting the neighbouring 
teeth, by ufing an inflrument that is quite 
fmooth or polifhed on one fide. 

This I believe to be the beft method hi- 
therto known of extracting firm teeth from 
the back part of either of the jaws ; and 
the incifores and canine teeth may like- 
wife be pulled in the fame manner : but 

thefe, 



Sect. IX. Difeafcs of the Mouth* 279 

thefe, namely, all the fore- teeth, as well as 
loofe teeth in every pare of the jaw, may 
be pulled in a different manner, which 
we fhall afterwards defcribe. 

Although there is fome difference, as we 
have already obferved, between the outer 
and inner plates of the alveoli of the teeth 
with refpect. to ftrength ; yet this is fo in- 
confiderable, that in pulling a tooth it me- 
rits little confideration. Neither is it a mat- 
ter of much importance to attend to the 
direction of the roots in the molares : For 
although it be alledged by fome, that thefe 
teeth may be turned with mod eafe to- 
wards the infide of the mouth, from their 
roots fpreading in general towards the out- 
fide of the jaw ; yet this is by no means 
the cafe. For the mod part, the roots of 
the large molares diverge equally towards 
both fides of the jaw ; fo that in this re- 
fpect they may be pulled with the fame 
propriety to the one fide as to the other. 
But the two laft molares of the lower jaw- 
afford an exception to this ; for they are 
fo fituated, that in every inftance where the' 

common 



2 &o Difeafes of the Mouth. Ch. XXX. 

common key is employed, they fhould be 
turned inwards. The bafis or origin of 
the coronoid procefs forms a ftrong fharp 
ridge on the outfide of the jaw, exactly 
oppofite to the roots of thefe teeth ; fo that 
when they are turned outwards, as the 
heel of the inftrument muft reft upon this 
ridge, the gums which cover it are necef- 
farily much bruifed and lacerated. As 
this is feldom attended to, I have feen va- 
rious inftances of much mifchief being 
done by it. When a tooth is much fpoil- 
ed on one fide, it is almoft the univerfal 
practice in pulling it, to fix the point of 
the claw on the found fide ; and as this is 
confidered as necefTary, it may be given as 
a reafon for our being obliged in fome in- 
ftances to turn even one of thefe teeth 
towards the outfide of the jaw. It is not, 
however, by any means necefTary that 
this fhould be univerfally adopted : for 
although in general it is fuppofed to 
anfwer beft to fix the claw of the inftru- 
ment on the founded fide of a tooth, and 
to turn it to the oppofite fide j yet with 



Se&. IX. Difeafes of the Mouth. 2 8 1 

a very little pains and attention we might 
perhaps in every inftance follow the very 
reverfe of this with equal fuccefs : for 
with a proper application of the fcarifica- 
tor we may almoft always feparate the 
gums fo efFedually as to be able to prefs 
the point of the claw far enough down 
upon the root, fo as to turn it with eafe 
to the oppofite fide. 

The key-inftrument, however, may be 
made fo as to turn even the two farthefl: 
back molares outward, without doing any 
injury to the gums lying above the procefs 
we have juft mentioned. A form of it for 
this purpofe' is delineated in Plate LIX. 
fig. 3. which I propofed feveral years ago, 
and which I have often ufed. By the heel 
of the inftrument retting upon the gums 
beneath the firft great molares, while the 
claw is bent in fuch a manner as to apply 
to the two pofterior teeth, thev may in this 
manner be turned out with fafety. The 
heel mould be made long, fo as to pafs far 
down upon the gum ; otherwife, for this 
particular purpofe, it will not anfwer fo 
Vol. IV. T well. 



282 Difeafes of the Mouth. Ch.XXX, 

well. Indeed the heel of the key-inftru- 
ment fhould be always longer than it is 
ufually made ; for when it is ftiort, it ads 
with much lefs power, and is more apt t6 
break the tooth, than when it is made of 
a greater length. The contrary of this I 
know has been much inculcated ; but af- 
ter having given a fair trial to both me- 
thods, I am now convinced that the key 
with a long heel is much preferable to the 
other. The principal objection that has 
been raifed to the ufe of a long heel is, 
that it muft bruife the gum more than 
when a thort one is ufed. This, however, 
is not the cafe, as will be readily allowed 
by any who attentively confiders the fub- 
ject : For even the fhortefl heel mull: prefs 
upon fome part of the gum ; otherwife, if 
it be applied upon the tooth itfelf directly 
oppofite to the point of the claw, as fome 
have advifed, it will act in nearly the fame 
manner, and with no farther power than 
the common forceps : While again, a long 
heel does not, as is commonly imagined, 
injure the gums in proportion to the 

length 



ii, >'r e i , \ 




Sea. IX. Difeafes of the Mouth. 283 

length of it : for although the flat fide of 
it be applied to the gum at firft, as* foon as 
it begins to act the fartheft extremity of 
it only will be found to touch them ; and 
accordingly this part^of the heel, as well as 
all the reft of it, mould be made as fmooth 
4s pomble ; fo that in turning upon xht 
gum, it will do lefs mifchief than when 
it is made rough according to the ufual 
form. 

We have already obferved, that in the 
pulling of teeth there is no caufe for being 
attentive to which fide they are turned, 
from any difference of ftrength between 
the outer and inner plates of the alveoli or 
fockets ; for in this refpect they are nearly 
fimilar. But even although the difference 
tvas greater than we find it to be, it fhould 
not be regarded : for in pulling a tooth in 
the manner we have defcribed, namely in 
an oblique or lateral direct on, it is evi- 
dent that the focket muft be brok, on both 
fides of it ; at leaft this muft be always tne 
cafe where the roots of the tooth are of 
the ufual length, and not ihortened, a> they 
T a fometimes 



284 Difeafes of the Mouth. Ch.XXX„ 

fometimes are, by difeafe ; for while the 
corona of the tooth is forced down upon 
one fide of the focket, the point of the root 
muft n^cefTarily be turned in nearly the 
fame proportion upon the other. The 
fo.'ttr part- will not indeed fuffer fo much, 
as they will not be bruifed by the heel of 
the instrument ; but it is clear that the 
focket muft be always much hurt by it : fo 
that in every point of view, little or no con- 
fideration is due in this operation to any 
diff rence that is fuppofed to take place in 
the ilrengrh of the two plates of which 
the fockets of the teeth are formed. 

But as it is of much importance to fave 
both fides of the alveoli as far as is poffible, 
nothing mould be omitted that can with 
any propriety be done to protect them. 
For this purpofe,a form of the key inftru- 
ment has been propofed, by which it is 
intended to fupport the gums and alveoli : 
while at the fame time the tooth is raifed 
and feparated from them, by turning the 
inftrument in the ufual manner. But if 
the focket be fo effectually fupported as to 

prevent 



PLATE LXT 




r. l — r r. •■■p' 



$e£l. IX. Difeafes of the Mouth. 285 

prevent it from yielding on the tooth be- 
ing prefTed towards it, there is much rea- 
ibn to fear that the tooth itfelf will break ; 
imd if the inftrument be not applied in 
fuch a manner as to have this effct, it 
will anfwer no other purpofe th-m che key 
in common ufe ; while, being more com- 
plex, it is managed with more difficulty. 
The propofal, however, is ingenious, and 
may lead to improvement in the operation 
of tooth- drawing*. 

In pulling a tooth with the key-inftru- 
ment it is the common practice to ft> ce it 
out at once. But although this may often 
fucceed, it is by no means advifable : for 
when the roots diverge much, or when 
any portion of the fang is enlarged, as is 
fometimes the cafe, we run a great rifk, by 
this method of breaking them, at the f *me 
time that the focket mult be much more 
broke than when the tooth is ioofened in 
T 3 the 

* This inftrument is the invention of Dr John Ait- 
ken. For a more particular account of it, fee Eflays 
•#n feveral important fubjects in Surgery. 



?86* Difeafes of the Mouth. Ch. XXX, 

the manner we have directed, by turning 
it firft to one fide and then to the other 
with the key-inftrument, €o as to be able 
afterwards to take it out with the common 
forceps. And if this be done flowly, with 
a gradual equal preffure, and if the heel 
of the key has been properly covered with 
feveral plies of foft old linen, fearcely any 
m fchief of importance can he done by it: 
But inftead of this, when the hard inftru- 
ment is applied directly to the gum, with- 
out the intervention of any fott fubftance, 
and when the tooth is turned out, as is 
fi quentlydone, byafuddenjerk, the gums 
will not only be greatly bruifed and lace- 
ra:ed, but the focket will be much more 
broke, at the fame time that the tooth it- 
felf will run a much greater rifk of being 
broke than when pulled in a more gradual 
manner. It is natural for patients who 
are ignorant of the rifk attending it, to 
wiih for the operation to be quickly done; 
but it is unpardonable in practitioners to 
indulge them in this, when a moment's 
reflection muft convince them, that it can 

feldom. 



Sect. IX. Difeafes of the Mouth. 287 

fcldom be done but wr.h much rilk of 
breaking either the jaw or the tooth. 

Even when the operation is done in the 
moft cautious manner, troublefome acci- 
dents will fometimes occur from it : And 
thefe particularly are, bruifing of the gum ; 
fplinters of bone being feparated from the 
jaw ; and alarming hemorrhagies. 

Laceration or even bruifing of the gum 
being a very painful part of the operation, 
it mould be prevented as far as poffible, 
not merely by covering the heel of the 
inflrument in the manner we have advifed, 
but by avoiding the application of it al- 
together, when it can poflibly be done, 
while the gums are much inflamed : for 
while the inflammation continues, the ope- 
ration proves necefTarily much more hurt- 
ful than it otherwife would do. For ob- 
viating the effects of laceration, when any 
fmall portion of gum is much feparated 
from the reft, it fhould be cut off with a 
pair of fcifTars ; the mouth mould be 
fomented from time to time with warm 
milk or any emollient decoction j and 
T 4 when 



«88 Difeafes of the Mouth. Ch. XXX, 

when there is reafon to imagine that fup- 
puration will take place, it mould be en- 
couraged by the application of roafted figs 
by way of cataplafm. In this manner, if 
an abfcefs occurs, it will be foon brought 
to maturation ; when, if it does not foon 
burft, it mould be opened : And again, in 
cafes of {lighter contufions, nothing alle- 
viates the pain induced by them fo effec- 
tually as the applications we have men- 
tioned. 

When the bone happens to be fpHnter- 
ed, if it is the focket merely that has fuf- 
fered, very little uneafinefs will probably 
enfue from it ; and thereto e it is fcarcely 
necefTary to mention it even to the patient. 
Bur when the fplinter extends to the more 
folic! part of the jaw, which in children 
efpecially is apt to happen, if the operation 
be not done with the utmoft attention, as 
the fore which enfues proves commonly 
tedious, and as it will not readily heal as 
long as any loofe pieces of bone remain in 
it, anv of thefe that are perfectly detached 
fliouki be taken away immediately ; but 

as 



Sea. IX. Difeafes of the Mouth. 289 

as they are feldom fo completely feparated 
as to come away eafily at firft, no force 
fhould be ufed in it, as they will afterwards 
either fall out of themfelves or will be ta- 
ken away without any difficulty, on a free 
formation of matter taking place. After 
this, if the matter be prevented from 
lodging, and if the confutation be in other 
refpecls found, the fore will probably heal 
with eafe. 

Hemorrhagies of importance do not fre- 
quently occur from tooth-drawing ; for 
the blood veflejs which fupply the teerh be- 
ing (mall, it is fcarcely poffible that much 
biood can be difcharged by them. But 
"when the roots of teeth are deeply fixed in 
the jaw, and when much force has been 
ufed in the operation, we can eafily fuppofe 
that in this manner fome of the larger ar- 
teries of the contiguous parts rmy be divi- 
ded ; and it is thus 1 imagine that any 
troublefome hemorrhagy which occurs here 
is ever produced. At firft we advife the pa- 
tient to take frequent mouth fuls of cold 
water, red wine, brand v, vinegar, or even 

alcohol ; 



290 Difeafes of the Mouth. Ch. XXX. 

alcohol ; and for the mod part one or other 
of thefe will prove fuccefsful j but when 
they happen to fail, other means muft be 
employed, and the eafieft of thefe is com- 
preffion. A doflil of foft lint being fitted 
to the opening, mull be pufhed into it; 
and the patient being defired to make a 
cenftant preffure upon it, by keeping the 
mouth fhut, if this be perfifted in for a 
Efficient length of time, it will very rarely 
fail. I have met with inftances, however, 
even of every trial of this kind proving 
unfuccefsful, and of fainting and other 
difagreeable fymptoms occurring from the 
violence of the hemorrhagy. In fuch a 
iituation the actual cautery is alone to be 
depended on ; and it muft be applied witlj 
freedom, otherwife no advantage will be 
derived from it. A fmall bit of lunar cau- 
ftic inferted into the opening might in 
fome cafes anfwer the fame purpofe ; but 
it does not ac"l with fuch certainty as the 
other, while at the fame time there is a 
greater rifk of mifchief being produced by 

it, 



Sect. IX. Difeafes of the Mouth, igi 

it, from its being apt to fpread fo as to in- 
jure the contiguous found parts. 

The key-inftrument which we have re- 
commended, is perhaps the belt. h;therto 
invented for the pulling of teeth in an ob- 
lique or lateral direction ; but there are. 
feveral others which are ufed in different 
parts of Europe that act nearly on the 
fame principles : Thefe, however, being 
lefs perfect, will not all be delineated here ; 
but with a view to convey fome idea of 
them to fuch as may not have an oppor- 
tunity of feeing them, 1 have given a re- 
prefentation of two of them in Plate LX. 
figs. i. and 2. But even thefe, although. 
they are the beft I have met with, are very 
inferior to the key : for they act with much 
lefs power; and they have this great defect, 
that they can never be employed for pul- 
Jing teeth towards the infide of the mouth. 
We have thus defcribed the method of 
extracting firm teeth from the back part 
of the mouth. Any of the fore-teeth may 
likewife be pulled, as we have already ob- 
served, with the fame inftruments j for they 

may 



292 Difeafes of the Mouth, Ch. XXX. 

may be turned either inwards or outwards 
by a proper application of the key : but 
they may alfo be pulled in a different man- 
ner ; and as this may be done with inftru- 
ments which do not bruife the gums, it 
fhould perhaps in every inftance be pre- 
ferred. 

The incifores and canine teeth, and even 
the two fmall molares, have only one root; 
fo that they are never fo firmly fixed in 
the jaw as the large grinders ; and there- 
fore they may be extracted with more eafe. 
For the moil part this may be done with 
the common teeth-forceps reprefented in 
Plate LXL figs. i. 3. or 4. In ufing this instru- 
ment, it mould be prefTed as far down up- 
on the tooth as poflible, otherwife it is apt 
to break off the corona or upper part of it, 
and to leave the root ; and the tooth mould 
not be pulled directly upwards, but mould 
be twifted alternately from one fide to the 
ether till it becomes loofe, when it may be 
taken out without further trouble. 

In fome cafes, however, even thefe teeth 
are too firmly fixed to admit of their being 

pulled 



PL4 rfi . LXjir 




Sect. IX. Difcafes of the Mouth. 293 

pulled with this inflrument : we have 
therefore given a reprefentation of forceps 
that act with more power y a very inge- 
nious invention firft made public in the 
Britifh Magazine in the year 1762. It is 
delineated in Plate LXII. figs. 1. and 2. 
Fig. 1. reprefents a common ftrong forceps 
with moveable claws. The axis of the 
claws is fhown at A. Fig. 2. is a fulcrum. 
£, C, is the handle going ofF obliquely 
from By by which it is more eafily applied. 
J5, F t Z), is. a plate of iron covered under- 
neath with a piece of fbft buff; and E is 
the other fide of the fame plate made 
round, fmooth, and uncovered. The tooth 
intended to be pulled is laid fad hold of 
with the forceps, fig. 1. then the fulcrum 
By F, D t is placed upon the neighbouring 
teeth, when the forceps being placed upon 
the round part of the plate E, by a pro- 
per motion of the lever G, //, 7, A", the tooth 
is in this manner to be extracted. In the 
pulling of loofe teeth, this inftrument may 
be ufed fo as to draw them nearly ftraight 
tip j and this we are told may even be done 

where 



294 Difeafes of the Mouth. Ch. XXX. 

where the teeth are quite firm, provided 
their roots do not diverge much, and that 
there be no ofleous adhefions between them 
and the fockets : but with a view to pre- 
vent any bad confequences that might oc* 
cur from the application of much force, 
we are defired by the anonymous author 
of the inflrument, inftead of attempting 
to pull firm teeth directly upwards, to 
twift them a little outwards, which loofens 
them fo much, that they may then be pul- 
led almoft in a perpendicular direction with 
much eafe. 

The advantages fuppofed to be derived 
from forceps with moveable claws is this : 
When the common forceps is ufed with 
immoveable claws, if the tooth be firm, it 
muft either be forced out obliquely, or the 
firft hold muft be loft, and the inftrument 
fixed again : but when the claws are move- 
able, it will always retain its hold, and the 
tooth will be pulled nearly in a perpendi- 
cular direction ; for the claws, by turning 
upon centres, will always fall into the way 

of 



Sect. IX. Dtfeafes of the Mouth. 295 

of the tooth ; and will therefore raife it 
very nearly in a ftraight line. 

We have taken different opportunities 
of obferving, that the moft painful part of 
tooth-drawing arifes from the bruifing and 
laceration of the gums and fockets j a cir- 
cumftance which cannot be altogether 
avoided when the key-inftrument is em- 
ployed. The great object of the forceps 
We have juft been defcribing being to pull 
in a ftraight direction, by which the gums 
and fockets are almoft entirely faved, would 
render it the moft complete inftrument 
that has hitherto appeared, were it not 
liable to fome very material objections. 
The ingenious author of this forceps thinks 
it may be employed for the extraction of 
any teeth ; even of the large molares : but, 
a* the mouth cannot be fo widely opened 
as to admit of the proper application of it, 
this mould never be attempted. It muft 
therefore be confined, as we have already 
obferved, to the pulling of teeth in the fore 
part of the mouth. But befides this, as 
the fulcrum is placed upon the contigu- 
ous 



2 9 6 Difeafes of the Mouth. Ch. XXX. 

ous teeth, when the tooth to be pulled is 
firmly fixed, it is fcarcely poflible to pre- 
vent thofe from being hurt : for they will 
be very apt to fuffer even when the pref- 
fure is made as nearly as it can be done in 
the direction of their roots ; and when 
this is not attended to with much exact- 
nefs, they are apt to be broke, or even to 
be forced entirely from their fockets. In 
the pulling of all loofe teeth, however, and 
whenever it is found that the fore-teeth 
are not fo firmly fixed as to require much 
force to move them, this inftrument may 
be employed with much advantage. When 
again, it is difcovered upon trial, tnat an 
unufual degree of force is neceffary, a 
prudent practitioner will rather lay the 
forceps afide, and finifh the operation with 
fome other inftrument. The common key, 
as we have already obferved, may be ufed ; 
or either of the inftruments, fig. i. and 2. 
Plate LX. may be employed for loofening 
the tooth ; after which it may be taken out 
either with thefe or with the common for- 
ceps. 

We 



Sea. IX. Difeafes of the Mouth. 2^7 

We have hitherto been fuppofing that 
the tooth to be pulled is only carious in a 
particular part, and that a confiderable 
part of the corona is ftill remaining. When 
a tooth becomes Co much difeafed that 
the upper part of it falls entirely off, fo as 
to leave little, or perhaps nothing, above 
the gum?, the remaining part of it is thus 
reduced to what is commonly termed a- 
Stump. 

In this ftage of the difeafe, the con- 
nexion between the remaining. roots and- 
the fockets undergoes a very importanc 
alteration. By the corona being remo- 
ved, the roots, whatever number there 
may be, are all feparated from each other ; 
for as they are united folely through the 
intervention of the corona, it is evident 
that their connection muft be deftroyed 
on this being taken away. In this man- 
ner their conne&ion with the fockets*' 
is rendered not fo firm as when diver- 
ging roots, tied together above, tend all 
to fupport each other ; but they become 
ftill more loofe by a difTolving or wafting 

Vol. IV. U proeefs', 



298 Difeafes of the Mouth. Ch.XXX, 

procefs, to which teeth in this fituation 
are particularly liable. A confiderable 
part of the corona of a tooth may be- 
come carious, and fall away, without 
any effect being produced upon the roots ; 
but I have fcarcely known an inftance 
of the corona being completely removed 
for any length of time, where the roots- 
did not fuffer a remarkable diminution. 
Nav, in fome cafes, the roots, even of 
the largeft molares, have been almoft 
completely annihilated j and inftead of 
the long fangs with which thefe teeth are 
furnilhed, only a fmall point or two of 
ipoiled bone has been met with. In con- 
fequtnce of this they become loofe ; and 
their connection with the jaw being now 
very fuperficial, they may be forced out 
much more eafily than it is pofhble to ex- 
trad a large tooth. I know that practi- 
tioners in general are of a different opi- 
nion, the pulling of a flump being for the 
molt part confidered as a more difficult as 
well as a more painful operation than the 
extraction of a large tooth. This, how- 
ever, 



Sect. IX. Difeafer of the Mouth. 299 

ever, can proceed only from want of ex- 
perience in this branch of practice ; for 
thofe who are more vcrfant in it know- 
well, that there is much more pain, ha- 
zard, and difficulty, in the palling of a 
complete tooth when firmly fixed, than in 
the taking out of feveral flumps. 

When the point of the claw can be for- 
ced fo far down upon a (lump as to get a 
firm hold, it may be pulled with the key- 
inftrument in the manner we have advi- 
fed for the extraction of large teeth ; but 
this lhould not in general be advifed, as we 
may commonly employ a fufficient force 
with inftruments which do no injury to 
the gums, and by which a very painful 
part of the operation may be avoided. 
When the (lump can be laid hold of ei- 
ther with the common forceps or with 
thofe with moveable points, this will be 
the eafiefl method of pulling it : but when 
it is fo much fpoiled as to be nearly, or 
perhaps entirely, covered with the gums, 
the points of the forceps cannot be pref- 
fed fufficiently down upon it ; in which 
U 2 cafe, 



306 Difea/es of the Month. Ch. XXX, 

cafe, we are under the neceflity of forcing 
it out with a fimple lever. This inftru- 
ment is commonly termed a Punch : dif- 
ferent forms of it are reprefented in Plate 
LXi 1 1. figs. 1.2. and 3. In ufing it, the gums 
muft be freely feparated from the ftump 
with a fcarificator ; and the point of it be- 
ing prefFed down upon the root, a degree 
of force muft be applied fufficient for rai- 
ling it completely out of the focket : and 
this being done with one of the fangs, the 
inftrument muft be applied in a fimilar 
manner to the reft of them. 

With thofe accuftomed to the ufe of the 
punch, this operation is fimple and eafy, 
while with others it is often both difficult 
and tedious. In order to be able to apply- 
as much force as pofiible, the point of the 
Inftrument is commonly pufhed as far as 
it will go towards the root of the fang : 
But by this means much of the force 
that is employed is loft againft the alveo- 
li of the oppofite fide ; which being firm- 
er and ftronger towards the bafe of the 
jaw, they do not fo readily yield at this 

part 



PLATE. LX111 




-t. FIG 



FICr. WM 6. FIG. I 



Sect. IX. Difeafes of the Month, 301 

part as" where they are thinner and not 
fo firmly fupported. In general, it will 
be found to anfwer better to pufli the in- 
ftrument no farther down upon the fang 
thanks merely necefTary for procuring a 
fomcient reft for the point of it ; for I 
know from experience, that a (lump may 
be forced out in this way with much more 
eafe than in any other manner. When it 
does not cpme out at once with the punch, 
but is merely loofened by it, it may in 
this ftate be laid hold of with the forceps, 
and removed in the manner we have al- 
ready pointed out. 

For the moft part, a punch of fiich a 
form as is reprefented in Plate LXI11. fig. 1. 
anfwers beft. With this the force is ap- 
plied fo as to pufh the fang towards the 
oppofite fide of the jaw ; but it fometimes 
happens that the upper point of the root 
is of fuch a form as does not fo readily 
admit of force being applied to it in 
this dire&ion : in this cafe we employ 
a kind of hook or crooked lever, fuch 
as is reprefented in fig. 3. by which the 
U X {lump 



5©2 Bifeafes of the Mouth. Ch. XXX. 

flump is drawn or raifed in a contrary di- 
rection. 

I have thus defcribed what by experi- 
ence I have found to be the fureft and ea- 
iieft method of extracting teeth. A va- 
riety of instruments may indeed be met 
with in other authors, which 1 have not 
mentioned, and by which it is faid, by the 
inveniors of them, that the operation may 
be done with more eafe. But this not be- 
ing fupported by the refult of practice and 
obfc rvation, it will not be expected that I 
fhould grwe any account of them, 

52.O/ Toothaeh from Inflammation. 

The ordinary fymptoms of toothach 
arife, for the mofl part, as we have al- 
ready remarked, from the nerve being laid 
bare, either from a tooth becoming ca- 
rious, or from the enamel being broke 
bv external violence. It fbmetimes hap- 
pens, however, in a very violent m nner, 
merely from an inflated ft ate of the 
membrane furrounding the root of a 

tooth, 



Sect. IX. Difeafes of the Mouth* 303 

tooth, or from the parts within the body 
of the tooth becoming inflamed. We 
judge of this being the caufe of toothach, 
when a fevere permanent pain attacks a 
tooth which outwardly appears to be found: 
and this efpecially when it has been evi-y 
dently induced by much expofure to cold; 
or when it is connected with other fymp- 
toms of inflammation, fuch as an infla- 
med ftate of the contiguous cheek, fwell- 
ing and fuppuration in the adjoining 
gums, &c 

In moft inftances, we may be able to 
trace this variety of toothach to the caufe 
we have mentioned, namely expofure to 
cold ; in fome cafes, however, it proceeds 
from caufes of a different nature. What- 
ever will produce inflammation in other 
parts of the body, will be attended with 
the fame effect when applied to the mem- 
brane furrounding the root of a tooth : 
and we know from experience, that inflam- 
mation of this membrane is fometimes in- 
duced by a difeafe to which the roots of the 
teeth are liable; what is termed theSwelling 
U 4. of 



394 "Difeafes of. the Mouth, Ch. XXX. 

of the Fang, a hard knot or exoftofis which 
now and then forms at the point of the 
root. At fir ft, the pain induced by this 
may be fuppofed to originate from diften- 
iion alone; but ultimately it commonly 
terminates in a very fevere degree of in- 
flammation. And inflammation of thefe 
parts, by whatever caufe it may be indu- 
ced, is always attended with a more vioi* 
lent pain than what, commonly rakes place 
from fimilar affections in other parts, ow- 
ing to their being here furrounded with 
bone, which prevents them from yielding 
fp readily to that diftenfion of the veflels 
with which inflammation is always ac- 
companied. 

In the treatment, of this variety of the 
difeafe, we will find in general, that thofe 
remedies prove moft fuccefsful which an- 
fwer beft in inflammatory affections of 
other parts. Local blood-letting, either. 
by fcarifying the contiguous gums with a 
lancet, or by the application of leeches, 
often gives relief. 1 have known the pain 
removed entirely by the application of a 

blifter 



Se6t.IX. Difeafes of the Mouth. 305; 

blifter directly oppofite to the part aff ^di- 
ed : and much advantage is often der: ved 
from a large dofe of laudanum j f jr. by- 
procuring a temporary diminution of pain, 
it thus lefTens irritation, and hence an a- 
batement of the inflammation itfelf. The 
head fhould be kept warm by covering it 
completely with flannel ; a practice which 
fhould be inculcated with all who are 
liable to toothach, from whatever caufe it 
may proceed, but particularly when it ori- 
ginates from inflammation ; and in this 
cafe fomenting the head with the fleams 
of emollient herbs, or even of warm water 
alone, will often procure relief when every 
other remedy has failed. In fome cafes 
indeed, cold water, vinegar, or ardent fpi- 
rits taken into the mouth, prove fervice- 
able ; but for the mod part warm appli- 
cations prove more ufeful in this variety 
of toothach. 

By a due perfeverance in the ufe of one 
or other of thefe remedies, the pain will 
commonly be at laft removed ; and in 
toothach arifing from inflammation, we 

are 



3<)6 Difeafes of the Mouth. Ch. XXX. 

are particularly induced to perfevere in 
applications of this kind, from our know* 
ing that the difeafe is not apt to return 
after it is once removed. But when 
they do not prove fuccefsful, we are under 
the neceflity of advifing the extraction 
of the tooth, which is often the only re- 
medy to be depended on. In extracting 
a firm tooth, we have already advifed it 
to be done in a flow gradual manner in 
every cafe, with a view to prevent the 
tooth from breaking, and the Jaw from 
fuffering fo much as it is apt to do when 
a tooth is forced quickly out. This cau- 
tion, however, is more particularly nece£» 
fary in the extraction of teeth under the 
circumftances we are now confidering; 
for when the pain originates merely from 
inflammation, without any part of the 
tooth being fpoiled, the roots are always 
entire, and more firmly fixed, than when 
the corona of a tooth is moftly confumed, 
and when the roots are always in fome de- 
gree decayed. And befides, when the pain 
and inflammation are induced, as we have 

already 



Se£. IX. Di/eafes of the Mouth. 307 

already remarked, by a fwelling or en- 
largement of the fang, and which can 
never be previoufly difcovered, if the 
tooth be turned quickly round, it will for 
certain break ; and the fwelled part of it 
being left behind, fcarcely any advantage 
will be derived from the operation, while 
all the pain and dirtrefs with which it is 
ufually attended will be feverely felt by 
the patient. 

On pulling a tooth which does not in 
any part appear to be carious, we are ad- 
vifed by fome practitioners to replace it 
and to tie it to the contiguous teeth till 
it become fufficiently firm. This I hive 
done in different inftances ; but 1 think 
it right to obferve, that it is a practice 
which frequently fails, owing, I pre fume, 
to the experiment being tried with teeth 
in a flate of inflammation. I know it 
will often fucceed where a tooth has been 
merely productive of pain, and when no 
fymptoms of inflammation have taken 
place ; but whenever the membrane fur- 
rounding the roots of teeth, or even when 

the 



£o3 Difeafa of the Mouth. Ch.XXX. 

the contiguous parts only arc much in- 
flamed, it will feldom or never fucceed, 
while at the fame time the trial of it will 
always be productive of much pain and 
diflrefs. It ought not therefore to be ad- 
vifed indifcriminately in every cafe, as has 
frequently been done. 

S 3* Of Toothach arijtng from Affeftions of dijlanf 
Parts, 

It is no common occurrence to find ail 
the fymptoms of toothach produced in the 
moft fevere degree, in one, two, or more 
teeth, where we cannot by the moft ac- 
curate examination difcover the Ieaft ap- 
pearance of difeafe ; where we are there- 
fore certain that no part of them is carious, 
and where there is every reafon to con- 
clude that the difeafe does not originate 
from inflammation. 

In fuch circumftances, as the patient is 
at firft always unwilling to part with a 
tooth which in other refpecls appears to be 
found, all the remedies ufually employed 

in 



Sect. IX. Dtfeafes of the Mouth 309 

In toothach are made ufe of; fuch as blis- 
ters, — blood-letting with leeches, — the ap- 
plication of ardent fpirits and ftrong ef- 
fential oils to the pained part, &c. ; and 
after being for fome days tormented with 
thefe, with little or no advantage, the pul- 
ling of the tooth is recommended as a 
never failing remedy. Even this fevere 
alternative is at laft fubmitted to ; but 
unfortunately no benefit enfues from it. 
The tooth in which the pain feems to be 
moft fevere is firft taken out : But the 
Contiguous teeth becoming fbon pained 
in an equal degree, they are from time to 
time all taken out, till at laft I have known 
all the teeth of one fide of a jaw extracted, 
and ftill the pain continue equally fevere 
in the gums as at firft. 

In fuch circumftances, we will often 
find, that the pain in the tooth is induced 
by an affection of fome other part, and 
that no remedy will prove effectual that is 
not directed to the original difeafe. It 
originates in fome inftances from rheu- 
Hiatifm j — it has been known to proceed 

from 



3io Difeafes of the Mouth. Ch. XXX. 

from an arthritic diathefis ; — it occurs as a 
frequent fymptom in hyfterical affections ; 
— pregnant women are frequently liable to 
it; — and it is often found to depend upon 
a foul Mate of the ftomach. 

When the pain originates from a foul- 
nefs of the ftomach, which may be often 
known by the ftate of the tongue, as well 
as other circumftances, no remedy proves 
fo effectual as emetics. 1 have known the 
moft violent toothach, which for many 
weeks had refilled the effects of every 
other remedy, almoft inftantaneoufly re- 
moved by a vomit : and when the fto- 
mach is once fufhciently cleared, a plen- 
tiful exhibition of Peruvian bark proves 
often effectual in preventing a return of 
it j particularly where the fits of toothach 
have returned periodically, as they fome- 
times do, fo regularly as to give caufe to 
imagine that they depend upon a tendency 
to ague. 

In this variety of toothach, arifing 
from an affection of the ftomach, no be- 
nefit is derived from laudanum. Inftead 

of 



Sect. IX. Difeafes of the Mouth. 3 1 i 

of procuring eafe, it feems rather to in- 
creafe the pain, and, by inducing ficknels, 
to render the patient in every refpect more 
miferable. But in thefe varieties of the 
difeafe, originating either from rheu- 
matifm, from gout, or hyfterical affec- 
tions, opiates will for the moft part re- 
move the pain entirely : and a return of 
it may be frequently prevented merely by- 
keeping the parts fufficiently warm. In 
hyfterical patients, a combination of lau- 
danum with ether has fometimes proved 
ufeful, when opiates in every other form 
have failed. 

Opiates are often ufed too in tooth ach 
induced by pregnancy ; but feldom with 
advantage. In large dofes indeed they 
fometimes procure a fhort relief from 
pain ; but nothing I have ever tried proves 
fb effectual in preventing a return of it as 
blood-letting. A plentiful difcharge of 
blood, by the application of leeches to the 
neighbouring gums, will fometimes an- 
fwer the purpofe ; but as the pain in cafes 
of this kind feems to originate from a ge- 
neral 



312 Dlfeafes of the Mouth. Ch. XXX. 

neral plethoric ftate of the fyftem, it com- 
monly proves more effectual to empty the 
veflels by taking away eight, ten, or twelve 
ounces of blood from the arm. I have 
known women immediately relieved by 
blood-letting, who for feveral weeks had 
been liable to very violent degrees of 
toothach, and in whom neither tooth- 
drawing, opiates, blifters, nor any other 
remedy, were productive of any advantage. 
When a practitioner finds that he has 
pulled a tooth in the circumftances we are 
now defcribing, where there is neither in- 
flammation nor much caries, he may with 
much propriety replace it. After clearing 
the tooth and focket entirely of blood, 
it fhould be put as nearly as poflible into 
its natural fituation ; where it fhould be 
tied to the two contiguous teeth till it be- 
comes fuffieiently firm. 



SECT. 



Sect. X. Difeafes of the Mouth. • 313 



SECTION X. 

Of Transplanting Teeth. 

r I ^HE advantages of a found fet of teeth, 
both with refpect to beauty and utili- 
ty, are fo great, that we are not furpri fed 
at finding the fertile genius of modern 
artifts employed in endeavouring to fupply 
the lofs of thofe which accident or difeafe 
may have occasioned. The method of 
fupplying deficiences of this kind with 
artificial teeth, and even of making com- 
plete fets of them, has been long known, 
and the art has by many dentifts been 
carried to great perfection ; but the trans- 
planting of human teeth from one living 
body to another is the invention of mo- 
dern artifts. The mere propofal of fuch 
a nice operation was intitled to much cre- 
dit ; and in no inftance does the art of 
furgery appear to more advantage than in 
rendering the practice of it perfect. It will 
Vol. IV. X * readily 



314 Difeafes of the Mouth. Ch. XXX. 

readily be conceived, however, that it is not 
admiflible in every cafe. Various eircum- 
ftances muft concur to render it practi- 
cable ; but it may commonly be clone 
wherever it is very neceffary. 

i. As it is in general more wich a view 
to obviate deformity, than to be productive 
of any real advantage, that the tranfplant- 
ing of teeth is practifed, it is feldom conu> 
dered as necefTary with any of the large 
molares. Indeed with thefe teeth it could 
not often take place j for as the roots of 
them often diverge in a very uncertain 
manner, and as the number and length of 
the roots can never be previoufly determi- 
ned, it would for the moft part be impoffible 
to procure teeth exactly fitted to the vacan- 
cies intended to be filled up. The practice 
is therefore confined almoft entirely to the 
incifores and canine teeth, although it may 
be done with nearly an equal certainty in 
the fmall molares ; for in them the roots 
are either iingle, or if there are two fangs 
they are almoft always united. 

a. In order to eniure fuccefs, the alveoli 

and 



Sea. X. Difeafes of the Mouth. 315 

and gums muft be perfectly found. They 
mufl be free from fcurvy and the lues ve- 
nerea j nor muft the patient undergo this 
operation for a confiderable time after a 
falivation. The ufe even of a fmall quan- 
tity of mercury frequently leaves fuch a 
foft fpongy flate of the gums, as renders it 
improper during the continuance of it to 
attempt any operation upon them. Hence 
thofe who are to have teeth tranfpianted, 
fhould carefully avoid even the rifk of 
contracting any complaint for the cure of 
which mercury may be necefTary * A 
patient being liable to gum-boils has been 
confidered as an objection to this opera- 
tion ; but where every other circumftance 
concurs to render it proper, it mould not 
be forbid by this : for although it would 
not probably fucceed where the furround- 
ing focket is carious ; yet we know that 
gum boils frequently occur where the 
focket is not in any refpecl: difeafed. 

X 2 3. As 

* This caution is particularly inculcated By the very' 
ingenious Mr John Hunter, in his Treatife on the Dif-J 
eaies o? the Teeth, page 98. 



3 i6 Difafes of the Mouth. Ch. XXX. 

3. As the fuccefs of the operation will 
depend in a great meafure not only on a 
found date of the alveoli, but on the foc- 
kets being full and complete, it will fel- 
dom anfwer where teeth have remained 
long in the (late of ftumps : for in this 
flate the roots commonly wafte away fo as 
to lofe confiderably both of their length 
and thicknefs ; and the alveoli diminifhmg 
in nearly the fame proportion, there is not 
fufficient fpace left for the roots of a found 
tooth to be fixed in. It may always, how- 
ever, be attempted where any consider- 
able part of the corona of a tooth is left ; 
for in this cafe the roots, as we have for- 
merly remarked, are ufually complete, 
however extenfrely the caries may in 
other refpeifts have fpread. 

4. It is in youth and middle age only 
that this operation is admifTible. In child- 
hood and old age it fhould not be attempt- 
ed. In childhood, it is not probable that 
a tooth put in, in this manner, would ever 
become firm, as the approaching tooth of 
the fecond fet would always be acting 

againft 



Setl. X. Difeafes of the Mouth.. 317 

againft it; and befides, as any vacancy- 
produced at this period will be filled up 
when the fecond fet comes forward, it can 
never be in any refped necefTary. In old 
age again, two ftrong objections occur to 
it. At this period the fockets of the teeth 
are commonly much diminifhed, particu- 
larly in depth : and in old age, when ma- 
ny of the fmaller blood-vefTels become ob- 
literated, it is not probable that any tranf- 
planted tooth, whether taksa from a dead 
or a living fubjecl:, would ever become 
fufficiently firm: For, when the operation 
fucceeds, as there is always a firm union 
produced between the tooth and the con- 
tiguous parts, by means of blood-vefTels 
pafling from one to the other, we are led to 
imagine that this is necefTary for the fuc- 
cefs of it. Now this, for the reafbn men- 
tioned above, can never happen to any ex- 
tent in advanced periods ot life. 

5. The tranfplanted tooth ought to fit 

the focket in every point as exactly as pof- 

fible : but it fhculd not require much 

X 3 force 



3 1 8 Dlfeafes of the Mouth. Ch. XXX. 

force to infert it ; for if it be in any de- 
gree larger, either in length or thicknefs, 
it will create a great deal of unnecefTary 
pain. The irritation produced by it will 
rirobably terminate in fuppuration ; and 
in this manner the operation will be ren- 
dered abortive. iSeveral people therefore 
ihould be provided for the purpofe of fur- 
nifhing teeth; fo that the operator may have 
no difficulty in rinding one of a proper fize : 
and it will frequently happen, thafa tooth 
of the fame fize taken from one perfon, will 
fit the focket of the lame tooth in another 
perfon very exactly. When it is found, 
however, that the roots of the tooth newly 
pulled are either too long or too thick fo* 
the focket in which they are to be placed, 
they mould be filed down till they go eafily 
in ; for it is not found that the removal of 
a fmall part of the root prevents the fuccefs 
of the operation. And care fhould be ta- 
ken to make the furface of the tranfplanted 
tooth fomewhat lower than the level of 
the contiguous teeth, fo that no incon- 
venience 



Seel. X. Difeafes of the Mouth. 319 

venience may occur from thofe in the op- 
posite jaw prefling againfl it. There is no 
neceflity, however, for this difference be- 
ing fo confiderable as to be very percep- 
tible ; for the fmalleft difference will an- 
swer the purpofe, and a greater degree 
of it will always be attended with fome 
deformity. 

But although we have faid that the 
roots of teeth to be tranfplanted may be 
leffened with a file, no part of the corona 
fhould be touched with it. It is fome- 
times indeed done by dentiits, and it may 
in fome inftances fucceed ; but as it muff, 
always be attended with fome rifle of the 
tooth becoming carious, it mould never be 
advifed ; and this efpecially as a very little 
attention will render it at all times unne- 
ceffary ; for although we maybe mifta- 
ken with refpecl to the fize of the roots of • 
a tooth, we have it always in our power to 
determine with exaclnefs, whether the up- 
per part of the tooth to be pulled will fit 
the vacancy or not. 

6. In taking out the new tooth and re- 
X 4 moving 



320 Difeafes of the Mouth. Ch. XXX. 

moving the old one, much care and atten- 
tion is neceffary ; for if the new tooth be 
much broke, or if the focket in which it 
is to be placed be much injured, the ope- 
ration will not probably fucceed. When 
it is poflible therefore to take out the old 
tooth with the forceps, it is better to do it 
in this manner than with the key-inllru- 
ment, which can fcarcely be ufed without 
injuring the parts too much. 

7. When the tooth is removed, the foc- 
ket cleared of blood, and the new tooth in- 
ferted under the reftrictions we have men- 
tioned, we are next to endeavour to keep it 
firmly fixed till an adhefion fufficient for 
retaining it takes place between it and the 
neighbouring parts. This mud be done 
by tying it to the two contiguous teeth, and 
by much attention on the part of fhe pa- 
tient to do nothing that can probably 
loolen it. In tranfplanting a canine tooth, 
the ligature, which mould be made of fe- 
veral plies of fine filk properly waxed, 
fhould be firfl tied round the upper part 
of the new tooth, immediately above where 

it 



Seel. X. Difeafei of the Mdutk 321 

it begins to fwell ; and on the tooth being 
properly placed, it fhould be tied to the two. 
contiguous teeth, taking care to pafs the li- 
gature as near as poflible to the gums. But 
when an incifor or fmall molaris is trant 
planted, it anfwers better to fix the liga- 
ture firft to the contiguous tooth near to 
the junction of the gums, and then to 
pafs it over the furface of the new tooth, 
and bringing it again back, to fix it 
where it commenced, round the necks 
of the other teeth. In this manner the 
tranfplanted tootlJ^is pulled down by the 
ligature into the focket ; but much atten- 
tion is necefTary in this part of the opera- 
tion to prevent it from being drawn too 
much either to one fide or another ; for 
nothingmorecertainlypreventsitfrompro- 
ving fu^cefsful than the new tooth being 
madeto prefs upon either of the contiguous 
teeth. This, however, will never hap- 
pen in the hands of an expert artifl who 
has been fufficiently accuftomed to this 
branch of practice j nor can it happen with 

any 



32* Difenfes of the Mmth, Ch.XXX. 

any who is properly warned of the confe- 
rences that may enfue from it. 

When the ligatures are properly fixed, 
they may not perhaps need to be renewed; 
but when they either flip off accidentally, 
or become in any degree loofe, they mould 
by all means be renewed immediately ; 
and the patient ihould be conftantly on his 
guard to avoid whatever might in any de- 
gree loofen or fhake the tooth. Nor is 
it fumcient to attend to this for a few days 
only : the fame kind c& caution mud be 
perfifted in till the teeth becomes perfect- 
ly firm ; and the length of time neceflary 
for this will depend on the circumftances 
of every cafe : on the particular ftate of 
the alveoli ; on the age and habit of body 
of the patient ; and on the operation being 
done with more or lefs exactnefs. ^Jn fome 
cafes a tooth will become perfectly fifan in 
the fpace of eight or ten days 1* while in 
others it will remain fomewhat loofe for 
two or three months. During all this pe- 
riod the patient mould live as much as 
poflible upon fpoon-meat : and he mould 

guard 



Sett. X. Difeafes of the Mouth. 323 

guard particularly againft cold ; for no- 
thing renders the fuccefs of this operation 
liable to fo much hazard as expofure to 
cold or dampnefs. 

The moft important objection that has 
been ftarted to the tranfplanting of teeth, 
is the rilk with which it is attended of com- 
municating difeafes ; and 1 mud own that 
a priori it appears to be a very material one. It 
hasnot however been found on experienceto 
be fufficient to counterbalance the advan- 
tages which are fuppofed to be derived from 
this operation; for it is daily practifed; and 
we feldom hear even of any fufpicion of in- 
fection being carried into the fyftem by it. 
I am not, however, of opinion, with thofe 
who think that dfTeafes cannot be commu- 
nicated in this manner. On the contrary, 
I think thofe practitioners do not deferve to 
be employed, who treat a matter of fuch 
importance to their patients with indiffer- 
ence. Teeth for the purpofe of tranfplant- 
ing mould never be taken from people 
with any appearance whatever of difeafe. 
Thofe only mould be ufed which are ta- 
ken 



324 Difeafes of the Mouth Ch. XXX. 

ken from conftitutions in which there is 
every poffihle evidence of health ; and 
with a view to prevent as much as it can 
be done, every rilk of infection being con- 
veyed in this manner, the tooth to be trans- 
planted fhould be immerfed for a few fe- 
conds in luke-warm water, and fhould af- 
terwards be entirely cleared of any blood 
or matter that may adhere to it, by rub- 
bing it gently between the plies of a piece 
of foft old linen. 

There is reafon indeed to imagine, from 
the refult of fome experiments made with 
a view to inoculate the meafles, as well as 
fbme other difeafes, with the blood of thofe 
infected with them, that infection cannot 
be communicated in this manner. But 
the point is by no means fo certain as to 
warrant our placing much dependence up- 
on it. 



SECT. 



Sea. XI. Difeafes of the Mouth. 325 

SECTION XI. 

Of the Ranula. 

\T7E frequently find tumors of differ- 
ent degreesof confidence feated be- 
neath the tongue, fometimes on one fide, 
and at others on both fides, of the fraenum; 
which in general are diftinguifhed by the 
term Ranula. They are feldom attended 
with much pain ; but they become fo large 
in fome inftances as to impede the fuck- 
ing of infants, and the maftication, and 
even the fpeech, of adults. In fuch cir- 
cumftances, the affiftance of furgery be- 
comes necefTary in the treatment of them. 
In fome cafes, tumors of this kind con- 
tain a fatty kind of matter : This, how* 
ever, is rare ; and for the mod part, per- 
haps in nineteen cafes of twenty, they are 
filled almoft entirely with a thin limpid 
liquor very much refgmbling faliva ; and 



326" Difeafes of the Mouth. Ch. XXX. 

we find, on cutting into them, that they 
are often produced by a floppage of the 
falivary duels from calculous concretions 
forming in them. They fometimes arrive 
at considerable degrees of magnitude ; but 
in general the tumor burfts when of the 
fize of a large nut, leaving an ulcer which 
is commonly difficult to heal, if the real 
caufe of the difeafe be not difcovered and 
removed. I have known an ulcer of this 
kind treated with much attention for the 
Ipace of feveral months — various deter- 
gent and even corrofive applications being 
employed for it — nay, in one inftance a 
long mercurial courfe was adminiftered, 
Dut with no advantage whatever ; and at 
Jaft, on the true origin of the diforder be- 
ing found out, it was cured in the fpace 
of a few days, merely by removing a por- 
tion of hard calcareous matter, which, by 
flopping the natural paflage of the faliva, 
firft produced the tumor, and afterwards 
prevented the ulcer, in which it termi- 
nated, from healing. In fome inftances 
concretions of this kind are (mall, not lar- 
ger 



Sect. XI. Difeafa of the Mouth. 327 

ger perhaps than the head of a middle 
fized pin ; whilft in others they are large. 
I have in different inflances found them of 
the fize of a kidney- bean. 

In every tumor of this kind that is not 
of a firm confidence, the moft effectual 
mode of treatment is to lay it open with a 
fcalpel from, one end to the other ; by 
which any calcareous particles contained 
in it are eafily difcoveiyd ; and thefe be- 
ing removed, the remaining fore common- 
ly heals eafily. There is no neceflity for 
warning the fore, as we are generally advi- 
fed, with tincture of bark and other aftrin- 
gents : On the contrary, warm water and 
other emollients anfwer better, by warn- 
ing out more effectually any particles of 
flone that may not have been previoufly 
difcovered. When indeed the fore proves 
afterwards difficult to heal, the others 
may fometimes be employed with advan- 
tage. 

The fame kind of management fhoutd 
be purfued in the treatment of old fiftulous 
fores of thefe parts. In almoft every cafe 

where 



328 Difeafes of the Mouth. Ch. XXX. 

where the difeafe is feated in any of the 
falivary glands or duels, it will appear to 
be kept up by the caufe we have mention- 
ed, namely a ftoppage of the duct by a 
particle of ftone ; and the removal of this, 
by making an incifion upon it, and turning 
it out with a probe or a fcoop, will very 
commonly accomplifh a cure. 

When, again, tumors in this fituation 
are of a fatty or gven of a firmer confift- 
ence, inftead of making an incifion into 
them, they mould be extirpated entirely ; 
and unlefs they lie deep, and are of a large 
fize, it may always be done with fafety, prac- 
titioners are very properly indeed afraid of 
hemorrhagies in this fituation ; for as the 
arteries He deep, it is always difficult, and 
mod frequently impoffible, to fecure fuch 
of them with ligatures as happen to be cut. 
But any tumor of this kind that is loofe, 
and not deeply attached to the contiguous 
parts, may be taken out without any rifk 
from fubfequent hemorrhagies ; for as the 
fuperfkial arteries of thefe parts are fmall, 

any 



Sea. XII. Difiafes of the Mouth. 329 

any difcharge that occurs from them, in 
genera], flops by the application of fpirit 
of wine— ^alcohol — or tincture of myrrh.—- 
In more violent hemorrhagies, it would no 
doubt be proper to employ tne potential or 
even the actual cautery ; but theie means 
are feldom neceflary. 

In removing tumors of this kind by 
difleclion, where they lie fo deep that they 
cannot be eafily laid hold of with tne fin- 
gers, the common fmall forceps is ufually 
employed; but a fmall hook with two 
fangs, fuch as is reprefented in Plate L. 
fig. 3. anfwers better. 



SECTION XII. 

Of Ulcers of the Mouth and Tongue, and 
extirpation of the Tongue. 

nPHE tongue and other parts within the 

mouth are liable to all the variety of 

ulcers incident to other parts of the bodv; 

Vol. IV. Y ' and 



33© Difeafes of the Mouth. Ch. XXX. 

and we need fcarcely remark, that the treat- 
ment of them mould be nearly fimilar. 
When they feem to originate from the 
lues venerea, fcrophula, or fcurvy, our 
views mould be chiefly directed to the 
cure of the general diforder of the fyftem ; 
while, on the contrary, local applications 
only mould be employed, when they appear 
to be of a local nature. 

Befides other caufes of ulcers, however, 
to which thefe parts are liable, it is proper 
to obferve, that there is one to which they 
are more particularly expofed, and which 
appears ro give rife to the greateft part of 
them, namely ragged teeth. I have known 
verv troublefome fores not only produced, 
but kept up for a great length of time, on 
the fides of the tongue, and on the infides 
of the cheeks, by the (harp points of bro- 
ken or carious teeth ; and as long as the 
rough pm of a tooth, which has once in- 
duced a fore of this kind, is allowed to re- 
main, no remedy whatever will heal the 
fore. In every cafe therefore of ulcer in 
the mouth, we fhould inquire with much 

attention 



Sea. XII. Difeafes of the Mouth. 331 

attention into the (late of the contiguous 
teeth ; and when any of them are found to 
be rough and pointed, they mould be m ide 
as fmooth as poflible with one of the f mall 
files, Plate LXlil. fig 5. or 6. Or when the 
fore appears to be induced by the forma- 
tion of tartar upon the teeth, it mould be 
effectually removed in the manner we have 
already advifed in the eighth fection of this 
chapter. 

The removal of the caufe is for the moft 
part foon followed by a cure of the fore ; 
but when this fails, we frequently derive 
fome advantage from warning the mouth 
with gargles compofed of decoctions of 
bark,-*-a folution of alum, — lime-water, 
— infufions of red rofe leaves — of oak- 
bark, — and other aftringents. 

In fome cafes, however, the fores be- 
come worfe, notwithftanding the ufe of 
jhefe, mercury, and every other remedy. 
They become ragged and unequal about 
the edges ; they difcharge a thin, fetid fa- 
mes ; and in this ftate they are commonly 
attended with much pain. 

Y 2 As 



332 Difeafes of the Mouth. Ch. XXX. 

As long as a fore of this kind remains 
fmall, without mowing any tendency to 
fpread, there is in general reafon to ex- 
pect a cure ; and therefore any violent re- 
medy is confidered as unneceflary : But 
whenever a lore has affumed the appear- 
ances we have enumerated, and when it 
does not yield to any of the means we 
have mentioned, as there will be little or 
no caufe to doubt of its being of a can- 
cerous nature, we fhould certainly advife 
it to be removed by extirpation, and it 
ought to be done without farther delay. 

A cancerous fore, whether it be feated 
on the tongue, or on the infide of the 
cheek, if it is only luperficial, and does 
not run deep, may be extirpated with eafc 
and fafety ; but when the fubftance either 
of the cheek or of the tongue is much af- 
fected, it becomes an object of more im- 
portance, as being attended both with diffi- 
culty and hazard. Whatever the rifk may 
be, however, if the difeafed parts can be all 
removed, the operation fhould certainly be 
advifed : for as we know of no other re- 
medy 



Sect. XII. Difeqfes of the Mouth. 333 

medy upon which any dependence can be 
placed for the cure of cancer, it is f.rely 
better to fubmit to fome rifle than to be 
left to certain mifery. 

When a deep-feated cancer in the cheek 
is to be removed, the eafieft and m®ft ef- 
fectual method of doing it is to make an 
incifion through the whole fubltance of 
the cheek, commencing at the contiguous 
angle of the mouth, and ending at the 
fame part, after furrounding the fore : 
The difeafed parts being thus entirely re- 
moved, the fides of the cut muft be laid 
as neatly as poflible together , and a num- 
ber of gold pins being introduced at pro- 
per diftances along the courfe of it, a 
cure will in this manner be completed by 
the twilled future in a manner fimilar to 
what is employed for the hair- lip, defcri- 
bed in Sedion 1. Chap XXX. In this 
way very extenfive cancerous fores may 
be removed without leaving much defor- 
mity ; while a very difagreeable unfeemly 
cicatrix is always left after the ufual me- 
thod of doing this operation, by removing 
Y 3 the 



334 Difeafes of the Mouth, Ch. XXX. 

the difeafed parts only, and allowing them 
to heal without drawing them together by 
futures. 

In removing ^any confiderable part of 
the tongue with the fcalpel, as the hemor- 
rhagy which enfues is the only occurrence 
from whence any danger is to be dreaded, 
the operator mould be previoufly provided 
with all the ordinary means of putting a 
(lop to ic. When ligatures can be pafled 
round the divided arteries, no other re- 
medy mould be trufted ; and this we may 
remark, may be done more frequently, 
and at a greater depth in the mouth, than 
is commonly imagined. As the tongue 
can be puthed a confiderable way out of 
the mouth, ligatures may be applied for 
this purpofe, even when a good deal of it 
has been t ken away, merely with the com- 
mon tenaculum or with crooked needles; 
but when this does not anfwer, it may 
fometimes be done in a manner fimilar to 
what we have defcrib^d in Section V. 
Chap. XXV11I. for the removal of fcir- 
rhous tonfils. A ligature being patted 

round 



Sea. XII. Difeafes of the Mouth, 33s 

round the artery with the needle ufed in 
fig. 3. Plate LI. it may then be tightly 
twilled by palling the two ends of it thro' 
the double canula, fig. 1. Plate XL IV. or 
a knot may be formed upon it with the 
inftrument, fig 2 Plate LI. 

When, however, it is found to be im- 
practicable to furround the divided arte- 
ries either in this way or in any other 
manner, we muft endeavour by fome other 
means to put a flop to the hemorrhagy. If 
the veflels are not large, keeping the mouth 
filled with aftringent gargles, either of al- 
cohol, a ftrOng folution of alum, diftilled 
vinegar, or water ftrongly impregnated 
with the vitriolic acid, will often anfwer : 
But when thefe do not fucceed, the poten- 
tial, or even the actual cautery, mult be 
employed as the laft refource. 

The removal of any confiderable part of 
the tongue we muft allow to be a very for- 
midable operation : as fuch it has been al- 
ways confidered ; and accordingly it has 
been rarely practifed. But, for the rea- 
sons mentioned above, I have no heii- 
Y 4 tation 



336 Difeafes of the Mouth. Ch.XXX. 

tationin faving,that it is fometime hecef- 
fary,and in general that it maybe done with 
fatety. lr ought not, however, to be at- 
temp red by every operator ; for as it is al- 
ways attended with a fudden difcharge of 
blood, the application of means proper for 
the ftoppage of this, obviating the effects 
of fainting, and other unexpected difficul- 
ties, which lometimes occur, require that 
fteady deliberate coolnefs which a natural 
fi: mnefs of nerves, conjoined with much, 
experience, alone can give. 



SECTION XIII. 

Of the Divifton of the Frjfnum Linguje. 

FT is fometimes found in children at 

birth, that the tongue is too clolely 

tied down to the bottom 01 the mouth, 

©wing to the trsenum being either too 

fhort, 



Sect. XIIL Difeafes of the Mouth* 337 

fliort, or continued too near to the point 
of it. The method of cure is obvious. 
This membrane or ligament mud be di- 
vided fo as to allow the tongue to have a 
free eafy motion ; and it mould be done 
as foon as it is obferved to be neceflary, 
other wife the fucking of the child imy in 
the firft place be impeded, and afterwards 
an inrerruption to fpeech mav arife from it. 

It is proper, however, to obftrve, that 
it is not a common occurrence ; for al- 
though nurfes often fpeak of children be- 
ing tongue-tacked, who either do not fuck 
readily, or that are backward in fpeaking, 
an attentive practitioner will feldom dis- 
cover it. 

The divifion of this membrane is an 
eafy operation ; but it muft be dune with 
attention, otherwife the contiguous blood- 
veflels will be apt to be injured, by which 
fuch a quantity of blood may be loft as 
might prove hurtful to an infant : It is 
Commonly done either with a fcalpel or 
with common fciflars ; but it is done both 
^vith more eafe and fafety with the in- 

ftrumeat, 



3 3 8 D Ifeafes of the Mouth, Ch. XXX. 

ftmment, fig. 3. Plate LXII. The child 

being laid acrofs the nurfe's knees, the fuf- 

geon mould open the mouth, and elevate 

the tongue with the index and middle 

finger of his left hand, while with the 

other he muft introduce the inftrument, 

fo as to receive the middle of the fraenum 

into the flit, which he may now divide 

with fafety to any neceflary depth. 



SECTION XIV. 



Of the Divifton of the Parotid Duct. 

r T" , HE parotid gland of each fide trans- 
mits the liquor which it fecretes bf 
a duel of the fize of a crow's quill, which, 
after paffing over part of the mafTeter 
mufde, penetrates the buccinator in an 
oblique direction, and empties itfelf intd 
the mouth about the middle of the cheek. 
In the operation which we Jhave juft de- 

fcribed, 



Sea. XIV. Difeafes of the Mouth, 339 

fcribed, of extirpating cancerous fores from 
the cheek, as well as by various accidents, 
this duel: is apt to be cut ; and if th^ two 
divided ends of it be not retained toge- 
ther till they heal, it often happens that 
the whole quantity of liquor which it 
ought to convey to the mouth is poured 
over the cheek ; and the difcharge being 
conftantly kept up, the fore is thus pre- 
vented from healing, and a fiftulous open- 
ing left correfponding to the fize of the 
dud. As the fore commonly heals alto- 
gether internally, the difcharge would ne- 
cefTarily continue during life, if means 
were not ufed for preventing it. 

In the cafe of a recent divifion of this 
duel, the befl practice is to lay the two ends 
of it as exactly together as poflible, and to 
retain them in this fituation till they are 
united ; by adhefive plafters, when this 
proves fufficient; or by the twifted fu- 
ture, when the retraction of the divided 
mufcle is confiderable : But when this has 
either been neglected at firft, or when it 
fails of fuccefs, as the diftant extremity of 

the 



34 o Difeafes of the Month. Ch. XXX. 

the duct foon heals, and is entirely oblite- 
rated at the divided end of it, owing to 
none of the fluid fecreted by the gland 
pa fling through it, the only way in which 
a cure can be obtained is to make an ar- 
tificial opening into, the mouth, and to 
endeavour to form an union between it 
and the upper part of the duct leading 
from the parotid gland. 

In making a paffage of this kind, we 
fhould carry it as much as poflible in the 
direction of the natural duel ; but in or- 
der to infure the fuccefs of it, it fhould be 
rather of a larger diameter than the other. 
For this purpofe a fharp- pointed perfora- 
tor of a proper fize fhould be entered on 
the other fide of the fore, exactly oppofite 
and contiguous to the under extremity of 
the fu peri or part of the duct ; and being 
carried with fome degree of obliquity, it 
jnuft in this manner be made to penetrate 
the mouth. This being done, a piece of 
lead probe, exactly the fize of the perfora- 
tor, fhould be introduced along the courfe 
of the newly-formed opening, to be re- 
tained 



Sea. XIV. Dlfeafes of the Mouth. 34.1 

tained in it till the fides of it become cal- 
lous ; when, the lead being withdrawn, 
the extremity of the duct mould be drawn 
into contact with the fuperior part of the 
artificial opening by means of a piece of 
adhefrve plafter, and kept in this fituation. 
till a firm union has taken place. After 
taking out the lead, we have it in our 
power to forward the cure, by rendering 
the end of the duct and of the newly formed 
opening raw with the edge of a lancet or 
fcalpel, before bringing them together, 
Till a firm adhefion takes place betweea 
them, the patient mould be directed (to 
live upon fpoon-meat ; to fpeak little ©r 
none ; and to make as little exertion with 
his jaws as poflible. \ 

In this manner, fores, which would 
otherwife continue to difcharge faliva for 
life, may be eafily healed, with fcarcely 
any mark of their having ever exifted. 
I have had three different inftances of it j 
in all of which complete cures were ob- 
tained. A common feton or cord of cot- 
ton has been recommended for this ope- 
ration 



34 2 Difeafes of the Mouth. Ch. XXX. 

ration inftead of lead ; and a bit of catgut 
has been ufed inftead of it : but nothing 
renders the parts fo quickly callous as 
lead ; and befides, it is more cleanly than 
a cord or tent of any fofter fubftance. 



CHAP. 



Sea. I. Difeafes of the Ears. 343 



CHAPTER XXXI. 



Of the Diseases of the Ears and Opera- 
tions praftifed upon them. 



SECTION L 



Of Deafness. 



DEafness may proceed from various 
caufes : for as a free paffage of 
found to the Tympanum or Drum of the 
ear, together with a found ftare of this 
membrane and of the parts connected with 
it, are requifite for the fenfe of hearing, 

£0 



544 Difeafes of the Ears. Ch. XXXI. 

fo whatever tends to obftruct the one, or 
to induce difeafes of the other, will nece£. 
farily be productive of more or lefs deaf- 
nefe. 

There are two paflages for the purpofe 
of conveying found to the ear ; one of 
them termed the Meatus hxternus, termi- 
nating in the external ear ; and the other 
the Tuba Euftaclnana, ending in the throat. 
It is true that the firft of thefe is of more 
importance than the other, for it is larger, 
and more conveniently placed for collect- 
ing found : but it is certain that the latter 
or internal pa/Tage is a very neceflary part 
of the organ of hearing ; for when by any 
means it is flopped, deafnefs to a greater 
or lefler degree almoft conftantly enfues. 
Thus we obferve, that any preternatural 
fulnefs or enlargement of the amygdalae, 
Specially when they are attacked with in- 
flammation, is always attended with fome 
degree of deafnefs. In this way, too, we 
account for that deafnefs to which patients 
are liable who have fuifered much from 
venereal ulcers in the throat; and poly- 
pous 



Sect. I. Difeafes of the Ears. 345 

pous excrefcences which extend back from 
the nofe and fauces, by comprefling the 
Euftachian tube, are frequently productive 
of a fimilar effect. 

In that variety of deafnefs which origi- 
nates from this caufe, a removal of the 
polypus, or of the ^welled amygdalae, will 
frequently accomplilh a cure, while no 
other remedy will be of any utility. But 
when the difeafe is the confequence either 
of an ulcerated ftate of thefe parts, or of 
much inflammation, as the extremity of 
the duct will probably be obliterated, it 
would be in vain to employ any means 
whatever. It has indeed been propofed in 
this variety of obftruction, to endeavour to 
open the duct, by inferting the end of a 
curved blunt probe into it, or even to 
inject milk and water, or any other mild 
fluid, into it with a curved fyringe. Buc 
although a perfon well acquainted with 
the anatomy of the parts, may, by much 
practice, arrive at fuch perfection as to 
be able to do this with little difficulty 
upon a dead body, there is fcarcely any 

Vol. IV. z reafon 



346 Difeafes of the Ears. Ch. XXXI. 

reafon to imagine that in pra&ice any 
advantage will be derived from it : for 
even in a healthy ftate of thefe parts, the 
irritation produced by the end of a probe 
or of a fyringe muft be fo confiderable as 
to render every attempt for inferring them 
very uncertain ; and the difficulty muft 
neceffarily be greatly increafed where the 
extremity of the duft is obftructed by dif- 
eafe. But if we have not much in our 
power in the treatment of deafnefs arifing 
from this caufe, we are in many inftances 
able to afford much relief, and even to re- 
ftore the moft perfect hearing where it has 
been entirely wanting, when the difeafe 
proceeds from obftruction in the external 
paffage of the ear. 

The meatus externus may be obftructed 
in various ways. It may be in an imper- 
forated ftate at birth ; — it may be more or 
lefs filled with extraneous bodies forced 
into it; — tumors or excrefcences may form 
in it ; — and it may be too much fluffed 
with wax, the natural fecretion of the 
part. As each of thefe caufes requires a 

method 



Sect I. Dlfeafes of the Ear's. 347 

method of treatment peculiar to itfelf, we 
fhall confider them under feparate heads. 

§ 1. Of an Imperforated Meatus Audit or ius. 

Among other natural deficiencies to 
■which the human body is liable, none oc- 
curs more frequently than an imperforated 
flare of fome of the pafTages. This is not 
fo frequently met with in the Meatus Au- 
ditorius as in others, owing perhaps to the 
lining membrane of this pafTage being every 
where attached to bone, by which it is pre- 
vented from collapfing. Notwithstanding, 
however, of this, different inftances have 
occurred of it, and fome variety is difco- 
vered in the nature of it. 

In fome cafes the obftruclion is formed 
by a thin membrane fpread over the mouth 
of the pafTage; while in others a confider* 
able part of the conduit is entirely filled 
with a flefhy kind of fubftance. 

In the treatment of this variety of deaf- 

nefs, nothing, it is evident, can be of any 

advantage but the removal of the caufe by 

Z 2 aa 



348 Difedfes of the Ears. Ch. XXXI. 

an operation. When this is determined 
upon, the patient's head mould be fecured 
in a proper light, and at a convenient 
height, by an afliftant ; when the opera- 
tor, with a fmall {harp-pointed biftoury, 
ihould make an incifion of a proper length 
exactly on the fpot where the external paf- 
fage of the ear mould terminate. If it is 
covered by a membrane only, the opera~ 
tion will foon be finifhed ; but when it is 
impervious to any great depth, the inci- 
fion mud be continued, by pafling the 
biltourv in a gradual manner farther in, 
either til) the refiftance is entirely remo- 
ved, or till there is reafon to fear that the 
tympanum would be hurt, if ic were 
carried deeper : in which cafe the inftru- 
ment mould be withdrawn ; and in order 
to prevent the parts from adhering toge- 
ther, a bit of bougie properly oiled mould 
be introduced, and retained till the cure is 
completed ; care being taken to remove 
it daily for the purpofe of cleaning it, 
and for wiping off any matter that may 

have collected in the ear. 

In 



Sect. I. Dijeafes of the Ears, 349 

In this manner deafnefs depending upon 
this caufe may often be removed when the 
obftruction lies between the tympanum 
and the farther extremity of the external 
pafTage ; and it ihould be always attempt- 
ed about the time when the child mould 
be beginning to fpeak. At a more early 
period the child would not be fo able to 
bear it ; and when delayed much later the 
fpeech would be impeded ; for we know 
that dumbnefs depends more frequently 
on a want of hearing than on any other 
caufe. 



$ t. Of Extraneous bodies imparled in the Ear. 

Although the vifcid nature of the 
wax of the ears is well calculated for 
preventing duft and other foreign mat- 
ters from getting accefs to them, yet we 
know that much diftrefs is in fome in- 
stances induced by this caufe. Children 
often pufh fmall peas, cherry- ftones, lead- 
drops, and other fuch articles into their 
% 3 ears, 



350 Difeafes of the Ears. Ch. XXXL. 

ears, and flies and other infects frequently 
crtep into them. 

When thefe lie near to the extremity of 
the paflage, flies and other things that can 
be laid hold of ftiould be extracted with 
fmall forceps, fuch as are delineated in 
Plate LXI. fig. 2. But peas and other 
round bodies are more eafily removed, by 
turning them out with the end of a cur- 
ved probe, or pafling the inftrument, Plate 
XLII. fig. i. behind them ; and their ex- 
traction is facilitated by a little oil being 
previoufly dropped into the paflage. 

When infe<5ts have got fo far into the 
ear that they cannot be taken out with for- 
ceps, the beft method of removing them is 
to wafh them out, by throwing in quan- 
tities of warm water, or any other mild li- 
quid, with a fyringe ; but as they adhere 
while living with confiderable firmnefs to 
the neighbouring parts, we fhould firft en- 
deavour to kill them, by filling the ear 
with oil, or any other liquid that proves 
poifonous to them, without injuring the 
tympanum. Lime-water, fpirit of wine, 

and 



Sea. I. Difea/es of the Ears. 35 1 

and many other articles, might be employ- 
ed for this purpofe- : but nothing proves 
fo harmlefs as oil ; and although it does 
not kill every fpecies of infecl inftantane- 
oufly, yet few of them will live if immer- 
fed in it for any length of time. The pa- 
tient mould therefore be defired to reft his 
head upon the oppofite fide ; and fome te- 
pid oil being poured into the affe&ed ear, 
it may thus be eafily kept in it as long as 
may be neceffary. 

Peas and other foft bodies which fwell 
with moifture, are apt to become fo large 
when they remain long in the ear, that 
they cannot but with much difficulty be 
extracted entire. In this cafe we mould 
endeavour to break them, either with the 
points of fmall forceps, or with a fharp 
fmall hook cautioufly introduced along 
the pafTage ; and as foon as they are fuf- 
ficiently divided, they muft either be taken 
out piece-meal with the forceps, or waihed 
out with a fyringe. 



Z4 §3- 



352 Difeafes of the Ears. Ch. XXXT. 

§ 3. Of Excrefcences in the Meatus Auditorius* 

We have already treated of polypi in the 
nofe and throat ; and we may now remark, 
that the external pafTage of the ear is equal- 
ly expofed to them. It is not indeed com- 
mon for excrefcences of this kind in the 
car to arrive at fuch a bulk as they do in 
the nofe ; but whoever has paid attention 
to this branch of practice, will acknow- 
ledge that they are by no means unfre- 
quent, and they often appear to be the 
caufe of very obftinate deafnefs. 

On examining the Meatus Auditorius, 
we fometimes find it filled with a poly- 
pous excrefcence hanging loofe by one 
pedicle; while on other occafions the paA 
fage is obftrudted merely by a thicknefs or 
fulnefs of the lining membrane of the ear, 
when no particular part of it appears to be 
more affe&ed than another. 

As the polypi of this part are ufually of 
a firmer texture than thofe excrefcences 
which occur in the nofe, and as the mem- 
brane 



Se&. I. Difeafes of the Ears. 353 

brane of the ear is firm, and does not rea- 
dily yield, they cannot with propriety be 
extracted with the forceps ; but they may 
be taken out either with the knife or by 
ligature. When they lie near to the exter- 
nal paflage of the ear, and can be laid hold 
of either with fmall forceps, or with the 
diflecling hook, Plate L. fig. 3. they may 
be eafily cut out with a probe-pointed bi- 
floury, fuch as is reprefented in Plate LII. 
fig. 3. and as they do not appear to be fo 
vafcular as fimilar excrefcences in the nofe, 
they may in this manner be removed with 
fafety ; for they feldom difcharge much 
blood. But when they lie deep, it is bet- 
ter to remove them with ligatures j for as 
the paflage is ftraight, a knife is in this fi- 
tuation introduced with difficulty, and u- 
fed with uncertainty. 

Various methods have been propofed of 
applying ligatures to excrefcences in this 
fituation ; but the method of removing 
polypi of the nofe, defcribed in the expla- 
nation of Plate XLVI. appears to be more 
advifable than any of them. With the 

forked 



354 Difeafes of the Ears. Ch. XXXI. 

forked probe, fig. 2. the doubling of a liga- 
ture may be pufhed up at one fide of a 
polypus till it reaches the root of it ; and 
the two ends of the thread being carried 
round the excrefcence, and inferted into 
a fhort double canula, fuch as is delinea- 
ted in Plate XL1V. fig. 1. the canula mull 
now be pufhed to the root of the poly- 
pus on the oppofite fide ; when the two 
ends of the ligature being drawn fufficient- 
ly tight, and fixed upon the knobs at the 
end of the tube, the probe may be with- 
drawn, and the polypus in all probability 
will drop in a day or two. 
> But it often happens, that thefe excref- 
cences cannot be removed in this man- 
ner ; for inftead of being pendulous by a 
fmall neck, they frequently extend a con- 
fiderable way along the lining membrane 
of the ear. In this cafe efcharotic appli- 
cations have been recommended : but as 
they cannot be employed but with much 
rifk of hurting the tympanum, they mould 
never be ufed ; and this efpecially as the 
difeafe may in general be removed by means 

of 



Sell. I. Difeafes of the Ears. 355 

of a more fimple nature. This affection 
of the membrane of the ear 1 confider to 
be very fimilar to that variety of obftruc- 
tion in the urethra in which bougies prove 
particularly ufeful ; and the fame remedy, 
when duly perfifted in, proves equally fer- 
viceable in the one difeafe as in the other. 
In the introduction of the bougie, care 
muft be taken not to pafs it to the depth 
of the tympanum, otherwife it may do 
more harm than good ; and the fize of it 
muft be enlarged from time to time till the 
paflage is rendered fufficiently open. 

When bougies are firft paffed into the 
ear, they are apt to create fome degree of 
uneafinefs, by irritating the parts to which 
they are applied ; but this foon. fubfides 
when they are employed with caution, and 
properly oiled before being introduced. 

§. 4. Of Deafnefs from Wax collected in the Ears. 

Whether it be from the lining mem- 
brane of the ear being pofTefTed of fome 
degree of a contractile power, or from the 

outward 



$$6 Difeafes of the Ears. Ch. XXXI. 

■outward extremity of the paflage being 
fbmewhat lower than the other, that the 
cerumen or wax does not ufually lodge in 
it is perhaps difficult to determine ; but it 
is certain, that in a healthy ftate of thefe 
parts they are for the moft part only thin- 
ly covered with this fecretion : fo that it 
does not appear furprifing that deafnefs 
fhould enfue when it is collected in large 
quantities ; for in this ftate it very effec- 
tually obftrucls the paflage of found to the 
tympanum. It commonly happens too 
when wax remains long collected in the 
ear, that it becomes thick, and even hard, 
infomuch that in fome inftances it becomes 
almoft as firm as a bit of timber. 

The treatment of this variety of deaf- 
nefs is very obvious. By an attentive ex- 
amination of the ear, we can diftinguifh 
with certainty whether there be a fuper- 
abundance of wax or not : for by placing 
the ear in a clear fun-fhine, we can fee 
even to the tympanum ; and whenever it 
is obierved that the paflage is much ob- 

ftru&ed 



Sect. I. DifeafcsofthcEars. 2>S7 

ftructed with wax, we lhould not hefitate 
in advifing it to be removed. 

Different methods have been propofed 
for clearing the ears of wax ; but the fafeft 
and eafieft is by warning or fyringing with 
warm water or any other mild liquid, fo 
as to force out all the fluff that is collec- 
ted. Milk and water, or foap and water, 
anfwer the purpofe as well as any other 
article : but before the operation a few 
drops of oil mould be poured into the 
ear, not with a view to difTolve the wax, 
for more powerful fol vents of this fub- 
ftance might be mentioned; but for the 
purpofe of lubricating the paflage, by 
which it is more eafily forced out. By a 
proper ufe of the fyringe, which a little 
experience will teach, the ears may be ef- 
fectually cleared of every obftruclion pro- 
ceeding from wax. 

Although obuTuction of the external 
pafTage of the ear is the mod frequent caufe 
of deafnefs ; yet it is proper to know, that 
in fome inftances it is produced in a dif- 
ferent manner. It may occur from a mor- 
bid 



358 Difeafes of the Ears. Ch. XXXI, 

bid ftate of the tympanum, and of the parts 
contained within it. To a certain degree 
it will take place, if either by accident 
or difeafe the external parts of the ear be 
deftroyed ; and it fometimes occurs from 
a deficiency of wax. 

Tn fcrophulous conftitutions the fmali 
bones of the ears fometimes become dif- 
eafed ; in confequence of which, a great 
degree of deafnefs is produced which is 
never in any inftance removed. In fuch 
cafes all that art can do, is to preferve 
the parts clean and free from fmell, which 
is moft effectually done by warning out 
any matter that may collect in the paf- 
fage, morning and evening, by throwing 
in a little warm milk and water with a 
fyringe : for if this be not attended to, 
the matter difcharged from the carious 
bones is apt to become ofFenfive ; and it 
commonly fubfifts either till the difeafed 
parts of the bones are entirely diffolved 
and difcharged, or perhaps during the life 
of the patient. 

We ought not, however, to confound 

this 



Sect. I. Difeafes of the Ears, 359 

this difeafe with a difcharge which fre- 
quently takes place from the ears, of a 
milder nature. In fome cafes it appears 
to be the confequence of a boil or abfcefs 
in the meatus externus ; while in others it 
occurs without any previous impofthume, 
and feems to be induced by fome flight 
inflammatory affection of the lining mem- 
brane of the ear, or perhaps of the tym- 
panum itfelf. 

This is a very common occurrence, and 
for the moft part I think it is improperly 
treated. In general it is fuppofed to ori- 
ginate from morbid humours in the fyf- 
tem ; fb that fome rifk is fuppofed to at- 
tend any attempt that may be made for 
flopping it. 

This however is an erroneous idea. In 
moft inftances it may be traced to the 
caufe I have mentioned, an inflammatory 
affection of the membrane of the ear ; 
which being of a local nature, no rifk 
can enfue from checking it. And accor- 
dingly I very commonly treat it with in- 
jections of a moderately aftringent nature, 

nearly 



360 Difeafes of the Ears. Ch. XXXI. 

nearly fuch as often prove effectual in put- 
ting a flop to the difcharge of a gonorrhoea. 
A weak folution of alum, or of faccha- 
rum Saturni, frequently anfwers, or French 
brandy fomewhat diluted. In fome cafes, 
putting a few drops of any of thefe 
into the ears, morning and evening, will 
prove fufficient ; but when this fails, 
they may be gently thrown in with a 
fyringe. 

It is proper to remark, that the earlier 
in the difeafe this practice is employed, 
the more effectual it ufually proves; fo 
that it fhould never be long delayed. And 
befides, when the difcharge has been of 
long duration, it is not only apt to do, 
harm, by relaxing, or even deftroying the 
tympanum, but fome rifk may occur from 
putting a fudden flop to an evacuation 
to which the fyftem has been for fome 
time accuftomed. The danger, however, 
may be obviated by the previous intro- 
duction of an iffue fomewhat adequate 
to the difcharge from the ear, either in 
the head, neck, or any other part; but 

in 



I'I...\Tk I,XI\ 




Seel. I. Difeqfes of the Ears* 361 

in recent cafes of this kind there is no ne- 
ceffity for putting the patient to any of the 
inconveniences with which an ifTue is fome- 
times attended; for here the difcharo-e 
may with fafety be flopped immediately. 
When deafnefs occurs either from re- 
laxation of the tympanum, or from any 
deficiency in the external parts of toe ear, 
(bme afuftance may be derived from our 
endeavouring to collect or concentrate 
found fo as to make a ftronger impreflion 
on the organ of hearing. Various mftru- 
ments have been invented for this purpofe; 
but none of them anfwers fo well as one 
nearly of the form of a common horn, 
fuch as is reprefented in Plate L XIV, fig. 2. 
Figure 1. is a convoluted tube employed 
for the fame purpofe; and fig. 3. repre- 
fents an inftrument intended to be con- 
cealed beneath the hair or wig, and to be 
fixed to the head by the two firings con- 
nected with it. 

When, again, a deficiency of wax is 
fufpeftedto be the caufe of deafnefs, drop- 
ping a little oil of almonds, or any other 

VQ.MV. A* mild 



362 Bifeqfes of the Ears. Ch.XXXI. 

mild oil into the ear, once or twice daily, 
proves fometimes ufeful. Ift Tome cafes 
too I have known advantage derived from 
inferring a little loft foap into the pafTage; 
which not only keens it moift, but by act- 
ing as a flimulus to the lining membrane 
of the ear, tends thus to induce a return 
of the fecretion of wax. With the fame 
view too, 1 have fometimes employed 
ftrained galbanum made into a proper 
confiftence with oil, aiong with a fmall 
proportion of the juice of an onion. 



SECTION IL 



Of perforating the Lobes of the Ears. 

T5 Y fome medical writers of the lad and 
preceding centuries, piercing the lobes 
of the enrs is recommended as an opera- 
tion that may prove ufeful in fome dik 
orders, particularly in affections of the 
head. In thofe times a fmall feton was 
drawn through the opening, with a view 

to 



Sect. II. Difeafes of the Ears. 363 

to induce a difcharge of matter, which in 
fome cafes might prove ufeful. At pre- 
fent this operation is never employed but 
for the purpofe of ornament. 

This is perhaps the moll fimple of all 
operations ; but as it is tuppofed to be of 
fome importance by thofe on whom it is 
practifed, it is neceflary to def bribe it. 
As heavy ear-rings are apt to tear the 
parts, the opening mould be made as high 
on the lobe as with propriety it can be 
done; and the fpot mould be previoufly 
marked with ink. The patient being feat- 
ed, and the head fecured by an amHant, 
the lobe of the ear mould be ftretched up- 
on a piece of cork placed beneath it. The 
furgeon is now to pierce it with theinftru- 
ment, fig. 6. Plate LXIV. and having pufli- 
ed it fo far through that the tubular part 
of it is freely out on the oppofite fide, the 
cork muft be withdrawn with the perfo- 
rator ftuck into it. A fmall piece of lead- 
wire is now to be inferted into the tube 
remaining in the ear; and on being drawn 
A a 2 into 



£$4 Difeqfes of the Ears* Ch. XXXL 

into the perforation, the lead muft be left 
in it. By moving it daily, which may be 
done with little or no pain, if it be pre- 
vioufly rubbed with oil, the pafTage wil| 
foon become callous, and thus the opera- 
tion is completed. 

Before concluding the chapter on the 
difeafes and operations upon the ears, it 
may be expected that we mould defcribe 
the method of cauterifing or burning be- 
hind the ears for the toothach. At one 
period this operation was much employed, 
and different inftruments were propofed 
for doing it. It is unnecefTary, however, 
to delineate any of them ; for the practice 
is now, we perfume, very generally laid 
afide*: and at any rate it may be done with 
a red hot probe of any kind equally well 
as with the neateft inftrument. It was 
fuppofed to prove ufeful by burning or 
deftroying the nerve producing the pain : 
but it would rather appear to adit by in- 
ducing terror or furprife ; and if this is 
tj*e cafe, it is probable that the fame ope- 
ration, 



Sedi. II. Difeafes of the Ears. . '3$$ 

ration would prove effectual if praiftifed ill 
any other part. But as the pain attend- 
ing it would by moft people be confider- 
ed as more fevere even than the pulling of 
a tooth, it is not probable it will ever be 
revived. • 



Aaa €HAt>, 



366 Of the Wry Neck. Ch. XXXIL 



CHAPTER XXXTI. 



Of the Wry Neck. 



THE Neck is fometimes confiderably 
bent to one fide : When this takes 
place to fuch a degree as to be productive 
of much deformity, the afliftance of fur- 
gery is in fome inftances employed for it. 
The Wry Neck m?y be produced in va- 
rious ways. It may depend upon an ori- 
ginal mal- conformation of the bones of 
the neck — Upon a preternatural degree 
of contraction in the mufcles of one fide 
of the neck, particularly of the fterno- 
maftoideus mufcle — Or, it may be indu- 
ced merely by a contraction of the fkin, 
in confequence of extenfive fores and 
burns. 

When 



Gh. XXXII. Of the Wry Neck. 36"; 

When the vertebras of the neck are 
diftorted, it would be in vain to attempt 
any means of relief; but either of the 
other caufes we have mentioned feem to 
admit of almoft a certain removal. 

In books of furgery the operation for- 
the wry neck is very commonly defcribed ; 
and as this deformity has in general been 
imagined to proceed folely from a con- 
traction of the fterno-maftoid mufcle, a 
divifion of this mufcle is ufually recom- 
mended as the only method of cure that 
can be depended on. Even Mr Sharpe 
was of this opinion ; and he delineates an 
inftrument termed a Probe-razor for per- 
forming it *. 

But were we even to admit that the di- 
vifion of this mufcle was a neceflary mea- 
fure, the method of doing it by introdu- 
cing the probe-razor beneath it and di- 
viding it afterwards, as is recommended, 
appears to be exceptionable, as being at- 
tended with much rifk of wounding the 
A a 4 con- 

* Vide Sharpe's Surgery, Cl.~ A ^XXV. 



3 68 Of the Wry Neck. Ch. XXXtf. 

contiguous blood-veffels : it would furely 
be better to divide the mufcle by repeated 
ftrokes of a fcalpel, and to continue the 
incifion in a gradual manner to fuch a 
depth as may be neceffary ; by which evea 
the large veins of the neck would be a- 
voided. But although we allow that a 
wry neck may be fometimes produced by 
a contraction of this mufcle, yet it appears 
to be a rare occurrence : I have met with 
different inftances of this deformity, and 
in all of them the contraction feemed to 
be in, the £kin alone. 

When the Ikin only is affected, the parts 
are more eafily feparated and with lefs rifk 
than when any of the deep-feated mufcles 
are to be divided : but even this mould be 
ilowly done, fo as to avoid the external 
jugular veins ; for although no great detri- 
ment might enfue from their being cut, 
we mould run no rifk of wounding them 
unneceffarily. But whether the caufe of 
contraction be feated in the fterno-maftoid 
mufcles or in the fkin, the incifion fhould 
be carried fo deep as to remove it effec- 
tually, 



Ch. XXXII. Of the Wry Neck. 369 

tually, otherwife little or no advantage 
will be gained by the operation. 

We ought not, however, to conclude, 
that our object is accomplifhed by the 
mere divifion of the contracted parts ; for 
unlefs fome method be employed to fup- 
port the head during the cure of the fore, 
it will ftill be apt to incline more to this 
fide than to the other, by which the parts 
newly divided will readily unite, fo that 
no advantage will be gained by the ope- 
ration. By Mr Sharpe and others we 
are indeed advifed to fluff the fore with 
lint, fo as to prevent this inconvenience 
with as much certainty as pbffible ; but I 
know from experience that this does not 
fucceed, and that nothing will anfwer but 
a firm fupport being given to the head. 
For this purpofe the inftrument reprefent- 
ed in Plate LXVI. fig. 1. will be found 
very ufeful : It was made for a cafe of 
this kind, in which it was ufed for feve- 
ral weeks, and with complete fuccefs. It 
mould always be wore not only till the 
ibre is heal, but for fome time there- 
after; 



3 7 o Of the Wry Neck. Ch. XXXII. 

after ; and if properly fitted to the parts 
upon which it refts, it is ufed without any 
uneafinefs. 

The fkin beneath the chin is fometimes 
fo much contracted in confequenee of 
burns and other caufes, as to draw the 
head confiderably down upon the breaft : 
The fame method of cure mull be prac- 
tifed for it that we have juft recommended 
for the wry neck. The contracted fkin 
mud be freely divided with a fcalpel, and 
the head mud be properly fupported from 
behind till the fore is cicatrifed. 



CHAP. 



Ch. XXXIII. Difeafes of the Nipples. 371 



CHAPTER XXXIII. 



Of Diseases of the Nipples. 



THE Nipples are in fbme cafes fo deep- 
ly funk in the bread, that a child in 
attempting to fuck, finds it difficult or 
even impoffible to lay hold of them. 

To remedy this inconvenience, different 
means are employed. If the prominent; 
part of the bread can be preffed fo far 
back as to uncover even a fmall part onljr 
of the nipple, it may commonly be drawn 
out by laying a (lout child of fix or eight 
months old to fuck it ; But as this cannot 

be 



372 T>ifeafes of the Nipples. Ch. XXXIll; 

be always done, glafles of different kinds 
are employed for the fame purpofe. In 
Plate LXV. fig. i. and 3. reprefent twd 
forms of glafles with which the breaft 
may either be fucked by the patient her- 
felf or by an afliftant ; and fig. 2. is a 
glafs cup mounted with a bag of elaftic 
gum. In ufing this the air mud be preffed 
entirely out of the bag, when the cup be- 
ing placed upon the breaft fo as to include 
the nipple, fuch a degree of ruction is 
produced as has a considerable effect in 
drawing it out. The bag, however, mould 
be much larger than it is commonly made ; 
for when of the ordinary fize, it does not 
act with fufficient force. But whichever 
of thefe means is employed, it ought to 
be perfifted in till the nipple is drawn 
fully out ; and this fhould be always dons 
immediately before the child attempts to 
fuck. 

The nipples, like every other part of the 
body, are liable to ulcerations ; but from 
their peculiar delicacy, any fores with 
wihch they are attacked, are always pro- 
ductive 



-I'l^VL'K I,' 




Ch. XXXIII. Difeafes of the Nipples. 373 

dnclive of much diftrefs, while the fuck- 
ing of the child tends not only to render 
them worfe, but of much longer duration 
than they otherwife would be. Cracks or 
chops in the nipples have not a formidable 
appearance, but they are commonly much 
more painful than ulcers of the greateft 
extent. 

Various remedies are employed for thefe 
affections, but emollients are moft fre- 
quently ufed : I have not found, however, 
that applications of this kind afford any 
permanent relief; for although they may 
give temporary eafe, this feldom if ever 
proves of long duration. Mild aitringents 
and drying applications are more to be de- 
pended on. As a wafh, lime-water pro T *s 
often ufeful ; and Port-wine and water, 
or brandy fufficiently diluted, may be em- 
ployed for the fame purpofe. After ba- 
thing the parts with one or other of thefe, 
the nipple fhould be covered with a bit of 
foft lint fpread with Unguentum Nutri- 
{um or Goulard's cerate j but of thefe the 



374 Bif cafes of the Nipples. Ch. XXXllt. 

firft is the beft : I have often ufed it with 
advantage, and I know of nothing that 
anfwers fo well in chops or cracks where* 
ever they are fituated. I find too, that it is 
much employed by my friend Doctor Ha- 
milton ProfefTor of Midwifery in this Uni- 
versity ; whofe practice being very exten- 
five, his authority may be relied on. It is 
proper, ho-vever, to obferve, that the nipple 
fhould be entirely cleared of this applica- 
tion always before the child is allowed to 
fuck ; for as lead forms the bafis of it, mis- 
chief might enfue from much of it being 
carried into the ftomach. 

Till the nipple is completely healed, the 
child mould not be allowed to fuck often- 
er than is altogether necefTary ; and when 
one of the nipples only is fore, this may 
be managed with little difficulty, as the 
child may be kept at the found breaft 
while the other may be drawn from time 
to time with a glafs, which does not injure 
the nipple. In Plate LXVI. figures 2. 3. 
and 4. fome fmall cups are reprefented for 

protecting 



I'l.ATE JjXVI. 




Gh.XXXIII. Difeafes of the Nipple*. 375 

protecting the nipples during the cure. 
When properly fitted to the parts, they not 
only protect them from the friction of the 
cloaths, but allow the milk to run off as 
quickly as it falls from the breaft. 



CHAP. 



$ 7 6 Of IJfues. Ch.XXXIV, 



CHAPTER XXXIV. 



Of I 3 S JJ E S. 



JSSUFS are fmall artificial ulcers which 
we form in different parts of the body, 
for the purpofe of procuring a difcharge 
of purulent matter. 

As I have elfewhere treated fully of the 
advantages that may be derived from i£» 
/ues, and of the manner in which they- 
feem to act in the cure of difeafes, it is not 
at prefent neceflary to enter minutely up- 
on this part of the fubject : I fhall there- 
fore only obferve in general, that I am 
daily more and more convinced of the 
utility of ifTues in the cure of long conti- 

nue4 



Ch. XXXIV. Oflfues. 377' 

riued fores, of whatever kind they may be; 
and. that I am ftill of the opinion that 
they act folely by difcharging a certain 
quantity of the ferous parts of the blood ; 
and not that they ferve merely as drains 
for the noxious humours in the blood, 
which till of late has been the prevailing 
idea upon this point *. 

Among other errors in practice which 
this opinion gave rife to, the choice of fi- 
tuation for ifTues was none of the lead 
remarkable. As it was imagined that ul- 
cers as well as other local affections were 
produced by a determination of morbific 
humour to a particular fpot, when ifTues 
were advifed, it was confidered as necefTary 
to place them as contiguous to the affect- 
ed part as pbffible, and always on the fu- 
perior part of the limb when the difeafe 
was feated on any of the extremities, in 
order to prevent the morbid matter from 
falling down to it. But as we now con- 
Vol. IV. B b elude 

* See a Treatife on the Theory and Management 
of Ulcers, Part II. Section I. where this fubject is 
more fully confidered. * 



378 Of Iffues. Ch. XXXIV. 

dude that iffues prove ufeful or otherwife 
merely by the quantity of matter which 
they afford, it appears to be of little impor- 
tance where they are placed ; and accord- 
ingly they may be inferted wherever the 
patient thinks they will occafion the leaft 
inconvenience. 

There are fome general rules, however, 
•which mould be attended to in the intro- 
duction of iffues : They mould never be 
placed immediately above a bone thinly 
covered — nor directly above a tendon — 
nor very contiguous to a large blood -vefTel 
or nerve — nor upon the belly of a mufcle. 
The beft fituation for iffues is that fpace 
■which lies between the tendons on the back 
part of the neck, where there is a confi- 
derable depth of cellular fubftance— the 
middle of the humerus, near to the 
infertion of the deltoid mufcle— and a 
confiderable hollow above the flexor ten- 
don on the infide of each knee. They may 
hkewife be inferted between two of the ribs, 
and on each fide of the vertebrae of the 
back ; or in fhort wherever there is a fuf- 

£cient 



Ch. XXXIV. Of lffues. 379 

c 

ficient quantity of cellular fubftance for 

the protection of the parts beneath. It is 
proper, however, to remark, that the fpot 
ufually fixed upon for iflues is perhaps 
the molt improper of any, I mean direct- 
ly below the knee ; where there is never 
much cellular fubftance ; where the veins 
of the leg can fcarcely be avoided ; and 
where they are apt to hurt the contiguous 
tendons. 

There are various ways of forming if- 
fues : By corroding or removing the fkin 
with epifpaftic applications ; — by making 
an incifion with a fcalpel or lancet ; — by 
the application of cauftic ; — and by the in- 
troduction of a cord. 

When an iflue is to be opened by remo- 
ving a portion of fkin, a blifter mull be 
applied upon the fpot exactly of the fize 
of the intended fore ; and on the blifter 
being removed, a difcharge of matter may 
be kept up, by dreffing the part daily 
with any of the common ointments in 
which there is mixed a fmall proportion 
of cantharides in fine powder: Or, itfome- 
B b 2 times 



3 8o Of Iffues. Ch. XXXIV. 

times proves fufEcient to ufe an irritating 
application of this kind, and a mild oint- 
ment of wax and oil alternately. 

In forming an iflue by an incifiorij or 
with cauftic, an opening muft be made of 
fuch a fize as appears to be fufEcient for 
affording a proper quantity of matter; 
and the opening muft be preferved by in- 
ferring daily into it fome extraneous body 
covered with any mild digeftive ointment, 
fuch as bafilicon orlinimentum Arcaei,while 
the whole muft be fecured witha proper ban- 
dage. Peas are commonly employed for this 
purpofe. Kidney-beans anfwer very well ; 
and fome make ufe of gentian root, and of 
aurantia Curaflaventia, ufually termed 
Orange Peas, turned into a proper form. 
When the opening is made by an incifion, 
the fkin mould be fupported on one fide 
by an affiftant, and on the other by the 
left hand of the furgeon ; who mould now 
with a fcalpel in the other make a cut of 
a fufficient length and depth for receiving 
the number of peas intended to be put 
into it, and thus the operation is finifhea: 

But 



Ch. XXXIV. Of/fuei. 381 

But when it is to be done with eauftic, 
more attention is requifite. The common 
lapis infernalis of different Difpenfatories 
aniwers beft : many compofitions of eau- 
ftic parte have been recommended ; but I 
have met with none that for this purpofe 
anfwers fo well. It mould be firft reduced 
to powder, and made into a patte wi:h a 
little water, or with fofc foap,when as much 
of it mould be applied upon the fpot where 
the iffue is wanted as will make an opening 
of a proper fize; but as it is apt to fpread to 
the contiguous parts, fome care is required 
to prevent it. For this purpofe a piece of 
leather fpread with Burgundy pitch or any 
adheftve plafter, with a fmall hole cut in 
the centre of it, fhould be placed upon the 
part with the opening direclly above where 
the eauftic is meant to be applied. The 
fmall fpot which is thus left uncovered, 
muft now be fpread with fome of the 
eauftic pafte ; and over the whole there 
mould be laid another piece of leather 
fpread with the fame kind of adhefive 
clatter, fo that there may be no chance of 
B b 3 any 



382 Of rjfues. Ch. XXXIV. 

any part of the cauftic efcaping. In the 
courfe of ten or twelve hours, the whole 
may be removed ; for before this, if the 
cauftic is good, it will have produced an 
efchar of a fufficient depth. In the fpace 
of three or four days, the efchar will fepa- 
rate from the contiguous found parts, 
when the opening formed by it muft be 
filled with peas or fome other of the fub- 
ftances we have mentioned. 

When it is an object to difcharge a large 
quantity of matter by an ifTue, and efpe- 
cially when we wifh to have it from deep- 
feated parts, we do it by the introduction 
of a cord of cotton or filk, forming what 
is commonly termed a Seton. This re- 
medy is often ; ufed with advantage in 
deep-feated pains, particularly in pains of 
the bread and fides in cafes of phthifis 
pulmonalis. In fuch cafes it is commonly 
inferted between two of the ribs j and it 
anfwers better in the direction of the ribs 
than when placed acrofs them, as is fome- 
times done. A cord is a frequent remedy 
too in aiFe&ions of the head, particularly 

in 



Ch. XXXIV. Of IJfues. zH 

in ophthalmia and other difeafes of the 
eyes ; and in fuch cafes it is ufually placed 
in the back of the neck. 

When we mean to introduce a cord, the 
parts a| which it is to enter and pafs out 
fhould be previoufly marked with ink; 
and the cotton or filk being put into the 
eye of the flat needle, Plate LXV1. fig. 5, 
and the parts being fupported by an aflift- 
ant, the needle mould now be puihed in 
at one of the fpots and carried out at the 
pther, along with two or three inches of 
the cord, which fliould be left hanging 
out. The irritation which the cord ex- 
cites foon produces a plentiful difcharge 
of matter, which may be increafed or dir 
minifhed at pleafure by covering the cord 
daily, before it is drawn, with a mi}d or 
an irritating ointment. 

In former times, it was a frequent prac- 
tice to form iffues by burning the parts, 
in which they were to be introduced with 
the actual cautery ; and in fome parts of 
Europe it is ftill continued : But as it is; 
Ipauch more terrifying than any ot thofe 
Bb 4 w ® 



384 Of IJJues. Ch. XXXIV. 

we have mentioned, and as it does not 
appear to be attended with any particular 
advantage, it is now in general laid afide. 
In China, Japan, and fome other eaftern 
countries, it is a prevailing practice, in 
deep-feated pains, to burn the parts affect- 
ed down to the bone with moxa. Moxa 
is a light, foft'down, of a particular plant. 
A fmall cone of it being wrapped up, the 
bafe of the cone is fixed upon the part 
with a little glue or mucilage ; and fire 
being put to the oppofite end of it, it is 
allowed to remain till the whole is confu- 
med ; and if one application does not prove 
iufficient, it is repeated once and again as v 
long as it is neceffary. The operation may 
be done equally well with fine flax ; but al- 
tho' it has been fometimes done in different 
parts of Europe, it is not probable that it 
will ever be generally practifed. I have 
known it, however, remove the moft ob- 
ftinate fciatic pains, where every other re- 
medy had failed. 



C H AP« 



Ch. XXXV. Of Inoculation, 38$ 



CHAPTER XXXV, 



Of the Inoculation of the Smal^-Pox, 



THERE is ground to imagine, that al- 
moft all eruptive difeafes, as well as 
fome others, may be communicated by in- 
oculation : the practice, however, is confi- 
ned to fuch as are not apt to return ; for 
no advantage would arife from inducing 
difeafes to which the fyftem might after- 
wards be liable. The plague has been 
communicated by inoculation ; but in this 
country the fmall-pox is the only difeafe 
we are accuftomed to inoculate. Some 
tjiajs have indeed been made for inocula- 
ting 



^86 Of the Inoculation Ch. XXXV. 

ting the meafles ; but as yet they have not 
fucceeded. 

From the refult of fome experiments, 
there is reafon to think, that no difeafe 
can be communicated by inoculating with 
the blood of an infected perfon. This 
point, however, is not as yet precifcly de- 
termined ; fo that farther trials will be ne- 
ceflary to afcertain it. In inoculating the 
fmall-pox, we employ the matter contain- 
ed in the puftules which appear on the 
furface of the body. 

The proper period for inoculating— the 
preparation of the patient-*— and the fiibfe- 
qnent treatment of the difeafe, are points 
which more particularly fall to the confi- 
deration of the phyfician. The mpde of 
communicating the infection is our object 
at prefent. 

In the more early practice of inocula- 
tion, it was cuftomary to tie an infeded 
thread round the arm or leg ; to rub a 
little variolous matter upon any part of 
the body ; or to inferc a piece of thread 
Soaked in matter beneath the cuticle, with 



Gh. XXXV. of the Small-Pope. 387 

a fmall needle, and to allow it to remain 
fill there was reafon to think the infection 
had taken place. In any of thefe ways 
;he fmall-pox may be readily communi- 
cated : but as by fome of thefe means 
there is reafon to fufpeft that a variolous 
atmofphere may be produced, and that the 
difeafe may be thus induced in the fame 
way as in the cafe of a common contagi- 
on, and confequently that fome of the ad- 
vantages of inoculation may not be obtain- 
ed, thefe modes of giving the fmall-pox 
have therefore been long laid afide. 

Till of late, inoculation was common- 
ly performed by making an incifion of 
about half an inch in length through the 
ikin to the depth of the cellular fub- 
ftance : a bit of thread impregnated with 
variolous matter was then inferted, and re- 
tained for two or three days by means of 
a comprefs and banda§p. To this prac- 
tice, however, the great tmneceflary pain 
attending it, and the aptnefsof the wound 
to degenerate into a difagreeable ulcer, are 
(trong obje&ions. 

The 



J 



88 Of the Inoculation Ch.XXXV. 



The prefent mode of inferting the mat- 
ter appears to be in every refpect more 
elegible. The point of a lancet, previoully 
covered with variolous matter, is infinua- 
ted through the cuticle fo as to fcratch or 
flightly injure the cutis vera. It might 
frequently indeed be fufficient to pafs 
it through the cuticle only ; but fuccefs is 
more certain when a fmall particle of 
blood follows the lancet. When the mat- 
ter is recently taken in an early period of 
the difeafe, the lancet may be introduced 
without being moiftened ; But whenever 
the matter has become firm and hard, it 
fhould be rendered perfectly foft with a 
drop of warm water, or by hplding it in, 
warm fteam. 

The operation may be done in any part 
of the body ; but the arm is generally pre- 
ferred. One fcratch would for the moffc 
part prove fufficient; but with a view to 
enfure fuccefs, it is right to make two or 
even three at the diftance of an inch from 
each other. It is to be obferved, how- 
ever, that when the matter takes effecT; in 

all 



Ch. XXXV. of the Small-Pox.' 389 

all the fcratches, the inflammation which 
enfues being communicated from one to 
the other, is often confiderable, and gives 
much pain and uneafinefs. This might be 
prevented by making the fcratches at a 
dill greater diftance, or even in diftinct 
parts of the body. One being made upon 
each leg or thigh would obviate every in- 
convenience of this kind. 

In this method of inoculating we ne- 
ver employ either bandage or comprefs ; 
for the wound is fo trifling that no kind 
of dreffing is necefTary : fo that we readily 
fee, at the end of the fecond or third day, 
whether or not the infection will take 
place ; for in general, by this time when 
the operation is to fucceed, the fcratches 
made with the lancet become red, fwelled, 
and fomewhat painful. 



E X P L A- 



Explanation of the plates. 



Plate XXXI& 

[Oppofhe to page ai.j 

Fig. t. The knife which Mr Pellier 
commonly employs iri extracting the ca- 
taract. It mould be highly polifhed, and 
£o very fharp as to penetrate the eye with 
eafe ; at the fame time that it fhould be of 
a fufficient ftrength for dividing the cor- 
nea without yielding. This, as well as 
the other two knives in this plate, are 
made to fit the handle I reprefented in Plate 
XLI. fig. 2. 

Fig. 2. A knife exactly of the fame form 

. v and 



Explanation of the Plates. 39 1 

and fize with the other ; only in this, that 
fide which pafles next the iris is round or 
convex, with a view to protect that mem- 
brane from being injured, which it is apt 
to be when the common flat knife is 
employed in eyes that are not promi- 
nent. 

Fig. 3. A probe-pointed knife, which 
in fome cafes may be employed with ad- 
vantage for finifhing the operation, when 
by any accident the aqueous humour 
efcapes before the point of the other knife 
has pierced the oppofite fide of the cornea: 
But for a more particular account of the 
method of ufing it, we mult refer to 
page 27. 

Fig. 4. A pair of curved fciflars of a 
proper fize for every operation on the eyes 
where fciflars are needed : Indeed every 
operator who praclifes much in this branch 
fliould be provided with them. 

Fig. 5. This is the only fpeculum which 
Mr Pellier employs. It may be made of 
gold or filver wire, or of any other me- 
tal. It is here reprefented of the full fize 

both 



392 Explanation of the Plates. 

both in length and in thicknefs of wire; 
In ufing it, one of the curves at A or B \i 
placed upon the upper eye-lid directly be- 
hind the cartilaginous border ; and be- 
ing given to an afliftant, a degree of force 
is applied with it fufficient for fixing the 
eye • which is eafily done, if the opera- 
tor at the fame time makes fome refinance 
by placing the index and middle fingers 
bf one hand on the tinder edge of the or- 
bit fo as to comprefs the eye beneath. 

All the inftruments of this plate are re- 
prefented of the full fize. 



Plate XL. 

[Oppofite to page 39.3 

Fig. 1. A curved needle fixed in a han- 
dle for 'the purpofe of pafling ligatures 
beneath the pterigium and other fmall 
excrefcencesj which now and then occur 
within the orbit, and even upon the eye 
itfelf. I have elfewhere mown that they 
may be removed without this precaution *: 

but 

• Vide Chapter XXVII. Section VIII. Vel. III. 



Explanation of the Plates. 393 

but as Mr Pellier is accuftomed to employ 
a Hgaturej 1 think it right to defcribe his 
method of inferring it. Fig. I. is intended 
for tumors on the right eye, and to be 
ufed with the left hand of the furgeon. 
Fig. 4. is for the left eye, and to be ufed 
with the right hand. 

Figs. 2. and 3. An inftrument which 
Mr Pellier names a Ciftatome, from his 
ufmg it in particular cafes for opening the 
capfule of the cryftalline leris. It may be 
made of gold or any other metal. In 
ufing it, he holds it between the thumb 
and two fore-fingers of his right hand ; 
taking care to place the thumb upon the 
button A or C, which is connected with a 
fheath that covers the fharp point B. The 
hand being fupported upon the cheek by 
the ring-finger and little-finger, the point 
of the inftrument covered with the fheath 
muft be cautioufly palled through the pu- 
pil till it reaches the lens ; when the but- 
ton C being drawn back with the thumb, 
the point of the inftrument will thus be 
fet at liberty without the hand being 

Vol. IV. C c moved. 



394 Explanation of the Plates. 

moved. This is an ingenious invention, 
and anfwers the purpofe with eafe and 
fafety. 

Thefe inurements are all reprefented of 
the full fize. 



Plate XLI. 

fOppofire to page $o.] 

Fig. I. An inftrument for deprefling the 
under eye-lid. "When an affiftant cannot 
be procured, it may often prove ufeful. 
The two flat hooks at the upper end of it 
being fixed upon the cartilaginous edge of 
the eye lid, the other end of it hanging 
over the cheek, by its weight draws it 
confiderably down. 

Fig. 2. A knife which Mr Pellier em- 
ploys in fome cafes for the operation of 
extracting the cataract. It is fixed in the 
handle at B by a male-fcrew fitted to a 
female- fcrew, which is turned by the nut 
A. This handle may be made to anfwer 
figures 4. and 5. as well as every knife 
employed in operations on the eyes. 

Fig. 



Explanation of the Plate*. $$$ 

Pig. 3. An inftrument for determining 
the quantity of fkin to be removed in the 
operation for the Trkhiafis or Inverfion of 
the Eye- lids. When it is found neceflary 
to remove a portion of fkin from beneath 
the under eye- lid, or from the fuperior 
part of the upper palpebra, it may be done 
with a common fcalpel, while an afliftant 
fu >ports or elevates it from the parts be- 
neath either with his fingers alone or with 
forceps made for the purpofe ; but this 
inftrument anfwers better, as by means of 
it the quantity of parts to be removed cart 
be afcertained and cut off with more preci- 
fion. 

Fig. 4. A knife for opening fmall col- 
lections of matter on any part of the eye- 
ball. Being blunt on the back and round 
on the end, it is ufed without any rifk of 
injuring the contiguous parts. 

Fig. 5. A fharp- pointed curved knife* 
for dividing the veflels of the eye or of the 
palpebrae. 

Thefe inftruments are all delineated o£ 
the full fize* 

C c a Plat* 



39^ Explanation of the Plate** 
Plate XLI1. 

[Oppofite to page 57.] 

Fig. 1. A fmall fcoop, which anfwers 
better than any other instrument for re- 
moving fmall ftones, peas, or any other 
fubftances from the noiinls or ears. 

Figs. 2. 3. 4. 5. and 6. Are inftruments 
employed by Mr Pellier for the operation 
of the Fiftula Lachrymalis. Fig. 2. is a 
perforator and conductor for clearing the 
paffage through the os unguis into the 
nofe. Figs. 5. and 6. are tubes for lea- 
ving in the paffage. Fig. 3. is a compref- 
for for fixing them after they are inferted ; 
and the eafiefl: method of inferring a tube 
is by putting it upon the conductor after 
it is paffed through the compreffor, as is 
reprefented in fig. 4. The conductor ar- 
med with the tube and the compreffor be- 
ing paffed through the paffage into the 
nofe, mull be withdrawn; when, by means 
of the compreffor, the tube may be firmly 
fixed. 

Thefe inftruments are all reprefented of 

the full fize. 

Plate 



Explanation of the Plates. 397 
Plate XLIIT. 

[Oppofite to page 74.] 

Fig. I. Forceps of a convenient form for 
extracting fmall bones or other fubilances 
from the throat. 

Fig. 2. An inftrument for preventing the 
noftrils from collapsing after the operation 
defcribed page 85. A B t Two moveable 
tubes for inferting into the noftrils, to be 
retained in their fituation by a ribbon paf- 
fed through the opening CD, and tied on 
the back part of the head. 

Fig. 3. A fide view of one of the tubes. 

Thefe inftruments are all reprefented of 
$ie fulj fize. They as well as fome others 
in this volume are taken from fome elegant; 
engravings publifhed by Mr Bambrilla of 
Vienna. 

Plate XLIV, 

[Oppofite to page 109.3 

Fig. 1. A double canula for the purpofe 
of fixing ligatures upon poly pous excrefcen- 
ces either in the nofe, throat, ears, or va- 
gina. The ligature pafTed through it may 
either be of catgut or pliable fiiver-wire. 
C c 3 Fig, 



398 Explanation of the Plates: 

Fig. 4. Is a canula for the fame purpofe, 
but of a different conftruction. When the 
Other is ufed, the ligature is tied round the 
handles of the inftrument. In this the 
ligature paflfes through a moveable handle, 
and is eafily turned tp any degree of tight* 
jiefs. 

Fig. 2. Is a canula of the fame kind 
with the others ; but being crooked, it is 
better calculated for removing polypi that 
are deeply feated in the throat. The me- 
thod of ufing thefe inftruments is defcri- 
bed in different parts of Section V. Chap* 
ter XXVII. 

Fig. 3. Is an inftrument for paffing a 
ligature over the uvula. A thread being 
pa(Ted through the tubular part of the 
handle with the probe -4, a noofe muft 
be formed upon it ; and being lodged in 
the groove on the infide of the ring, the 
other end of %he thread muft be palled 
through the two fmall holes on the out- 
fides of the ring; and thus it is ready for ufe. 
It is commonly termed the King of Hilda- 
iius t from the name ot its inventor. A1J 

tfcefe 



Explanation of the Plates, 3^9 

thefe inftruments are rcprefented of the 
fullfize. 



Plate XLV. 

[Oppofite to page 1 1 7.3 

Fig. I. A fection of the bones of the head, 
reprefenting a polypus in the throat hang- 
ing down behind the velum pendulum 
palati, with a ligature patted over it and 
fixed at the root of it, with a double ca- 
nula inferted through one of the noftrils. 

Fig. 2. This figure is taken from Mr 
ChefeJden. It reprefenrs a polypus in the 
nofe, with part of it pafling back into the 
throat, and the reft into the noitril, with 
a ligature inferted from the noftnl into 
the throat, in fuch a manner as to include 
the root of the excrefcence inks doubling. 
By afterwards twifting the ends of it, a 
degree of compreflion may be applied up- 
on the root of the polypus iufficient for 
removing it ; but it would not anfwer in 
every cafe ; and as the fhethod with the 
Canula is not only more eafy but more ef- 
C c 4 fectual, 



4oa Explanation of the Plates* 

feelual, the other will never probably bo 
ufed. 



Plate XLVI. 

[Oppofite to page i to.^ 

Fig. I. A polypus of fuch a fize that it 
diftended the noftril completely. It was re- 
moved with a ligature as is here reprefented. 
y4, The extremity of the polypus which 
appeared without the noftril. C, A probe 
of filver or any other metal, fplit at the 
end, in fiich a manner as to retain a piece 
of catgut or filver-wire ; the doubling of 
which being inferted into it, fhould be 
pufhed up to the root of the polypus on 
one fide, while the tube B being pafTed 
upon the two ends of it, muft be pufhed 
up to the root of it on the oppofite fide, 
when the ligature may be eafily drawn to 
any necellary 1 degree of tightnefs. 

Fig. 3. A flit-curved probe, which may 
be ufed for t% fame purpofe, viz. for ap- 
plying a ligature to the root of a polypus 
in tumors featecftin the_ throat. By this 
fimple invent ... ..-.^T^ture may be carried 



to 

1 1 j 



Explanation of the Plates. 40 1 

to the root of every polypus that can oc- 
cur, however much the noftril may be 
cliftended by it. 

Plate XLVII. 

[Oppofite to page 122.] 

Fig. 1. An inftrument for the purpofe 
of applying cauftic to any part of the 
mouth or throat. It may be made of fil- 
ver or any other metal. A t A moveable 
tube in which the cauftic muft be fixed, 
when by pulling the ring at the other end, 
it muft be drawn fo far into the fur- 
rounding canula as to be completely co- 
vered with it ; when the end of the inftru- 
ment being applied upon the part affected, 
the cauftic muft be again pufhed forward 
to a proper length, which may be always 
afcertained with exactnefs by means of the 
finall pin tied by a thread to the ring at 
the oppofite end of it. This, as well as the 
inftruments of Plate XL VI. I am favoured 
with by Dr Monro, whofe improvements 
in furgery are numerous and important. 

Figs. 2. 3. and 4. Are different parts of 

an 



402 Explanation of the Plates, 

an inftrumcnt mentioned in page III. for 
the purpofe of putting a ligature round a 
polypus in the throat. 

Fig. 2. A waxed thread with a noofe 
adapted to the fize of the groove in the 
ring CD, fig. 3. ED, EC, Two tubu- 
lar pieces of brafs two inches and a half 
long, fupporting the ring which is placed 
horizontally upon them. At the upper 
ends of each they mould be made perfect- 
ly fmooth and round, fo as to allow the 
thread to Aide more eafily, and to prevent 
it from being cut by the edges of the 
tubes. CD, The apertures where the ends 
of the thread are inferted. E, One of the 
openings at which they are brought out. 
The other opening cannot be feen in this 
view of the inftrumcnt. The handle of 
the inftrument is of ftrong brafs wire fe- 
ven or eight inches long, and is bent a 
little that it may be the more eafily intro- 
duced. 

Fig. 4. An inftrument for making a fc- 
cond noofe. F, Two brafs wheels fixed in 
a fmall cafe of brafs. The two wheels 

are 



Explanation of the Plates. 403 

are five- eighths of an inch broad, and half 
an inch deep. After forming a fecond 
noofe, the ends of the thread mould be 
parted over the wheels in the manner here 
reprefented, when the handle of the inftru- 
ment being puftied upwards, a knot may- 
be formed of any degree of tightnefs. 

This inftrument is evidently formed 
upon the fame principle with the ring of 
Hildanus, Plate XLIV. fig, 3. 



Plate XLVIII. 

[Oppofite to page 1 26.] 

Fig. I. Curved forceps for extracting 
polypi from the throat, and from behind 
the velum pendulum palati. 

Fig. 2. Straight forceps for extracting 
polypi from the noftrils. 

Fig. 3. Forceps for the fame purpo(e 
with the laft, but fomewhat different in 
form. The method of uling both thele and 
the others is defcribed in Chap. XXV 11 1. 

t. v. 

Plate 



404 Explanation of the Plates. 
Plate XLIX. 

[Oppefite to page 144-] 

Figs. 1. 2. and 3. Different forms of cur- 
ved fchTars, for extirpating tumors within 
the mouth, as well as for other purpofes. 

Fig. 4. An inftrument nearly of the form 
of a fleme, which anfwers better than any 
other for fcarifying the gums of children 
in dentition. 



Plate L. 

[Oppofite to page I $4.] 

Fig. I. A fcarificator for ieparating the 
gums from the roots of teeth intended to, 
be extracted : It mould be very {harp, but 
at the fame time not fo fine in the point 
or edge as to be hurt by being infinuated 
between the gums and the teeth. 

Fig. 2. A curved trocar for perforating 
the antrum maxillare. 

Figs. 3. and 4. Two diflecling hooks 
with two and three prongs, which antwer 

better 



Explanation of the Platet, 40^ 

better for many purpofes than the fingle 
pronged hook in common ufe. 



Plate LI. 

[Oppofite to page 160.3 

Fig. 1. An inftrument for pafling a li- 
gature round the uvula or any other pen- 
dulous excrefcence in the throat ; but al- 
though the propofal is ingenious, it does 
not anfwer the purpofe fo well as the in- 
ftruments delineated in Plate XL1V. fi- 
gures 1. 2. 3. and 4. 

Fig. 2. An inftrument firft propofed by 
Mr Chefelden for tying a knot upon 
fcirrhous amygdalse after pafling a ligature 
through the bafis of the tumors, in the 
manner reprefented in fig. 3. The pin in 
fig. 2. is meant to reprefent a part upon 
which a knot is to be formed. 



Plate LII. 

[Oppofite to page 164.] 

Fig. i . An inftrument for removing the 
uvula by excifion. That part of the uvula 

intended 



406 Explanation of the Plates. 

intended to be removed being patted thro' 
the opening in the body of the inftrument, 
the cutting Aider, which ought to be very 
lharp, mult be preffed forward with fuffi- 
cient firmnefs for dividing it from the 
parts above. 

Fig. 3. A curved probe-pointed biftoury 
for removing fmall tumors in the throat 
or any part of the mouth : And fig. 2. for- 
ceps for laying helfd of tumors intended to 
be removed in this manner. 



Plate LIII. 

[Oppofite to page 1 70.] 

Figs. I. and 2. Two fcarificators of dif- 
ferent forms for opening abfeefles in the 
throat, and for fcarifying the amygdalae. 
The two wings with which the canula of 
fig. 1 . is furnifhed, are intended for com- 
prefling the tongue, while the point of the 
inftrument is pafled more deeply into the 
throat. 

Figs. 2. and 4. Mr Mudge's machine 
for conveying fleams of warm water and 

other 



Explanation of the P lates. 4.0 7 

other liquids to the throat and bread. 
Fig. 2. The inhaler as it appears when fit- 
ted for ufe, except that the grating J t 
which then ought to cover the hole, is now 
turned back, to fhow the opening into the 
valve. Fig. 4. A fection of the cover, in 
which is fhown the conftruclion of the 
cork- valve i?, and alfo the conical part C, 
into which the flexible tube D is fixed. 

When the inhaler, which holds about a 
pint, after being three parts filled with hot 
water, is fixed at the arm-pit under the 
bed-cloaths, the end of the tube E is to be 
applied to the mouth ; the air, in the act 
of infpiration, then rufhes into the aper- 
tures F, and paflmg through the hollow 
handle, and afterwards into a hole in the 
lower part, where it is foldered to the body 
and therefore cannot be reprefented, it 
rifes through the hot water, and is recei- 
ved into the lungs, impregnated with va- 
pour. In exfpiration, the contents of the 
lungs are difcharged upon the furface of 
the water ; and inftead of forcing the wa- 
ter back through the hollow handle, the 

air 



4©8 Explanation of the Piatei. 

air efcapes by lifting the round light cork- 
Valve By fo as to fettle upon "the furface of* 
the body under the bed-cloaths. 

Thus the whole act of refpiration is per- 
formed, without removing the inftrument 
from the mouth* 

The flexible part of the tube D is about 
fix inches long, fitted with a wooden mouth- 
piece E at one end, and a part G of the 
fame materials at the other, to be received 
into the cone C on the coven This flexible 
tube is made by winding a long flip of 
filk oil-fkin over a fpiral brafs-wire. This 
fhould be then covered with one of the 
fame fize, of thin filk, and both be fecured 
by ftrong few in g filk wound fpirally 
round them. Some length and degree of 
flexibility is neceflary to this tube, for the 
fake of a convenient accommodation to 
the mouth when the head is laid on the 
pillow. 

Care fhould be taken by the work- 
man, that the cover be made to fit very 
exactly ; or, if it does not do fo, the 
defect fhould be remedied by winding a 

piece 



Explanation of the Plates. 409 



piece of cotton wick, or fome fuch contri- 
vance, round the rim underneath the co- 
ver, fo as to make it air-tight. The cork, 
likewife, which forms the^alve, . fhould, 
for the fame reafon, be mroe as round as 
pomble. It is alfo necefTary to remark, 
that the area of the holes on the upper 
part of the handle taken together ; the fize 
of the hole in the lower part of the handle 
which opens into the inhaler ; the opening 
of the conical valve itfelf ; and that in the 
mouth-piece ; as well as the cavity or infide 
of the flexible tube, fhould be all equally 
large, and of fuch dimenfions, as to equal 
the fize of both noftrils taken together : 
in fhort, they fhould be feverally fo large, 
as not only not to'obftrucT: each other, but 
that refpi ration may be performed thro' 
them with no more labour than is exerted 
in ordinary breathing. 



Vol. IV. Dd Plats 



4 r o Explanation of the Plates. 

Plate LIV. 

[Oppofite to page 200] 

. Fig. 1. A fpeculum oris, which I pro 
pofed a confiaerable time ago, and which 
in different cafes has been ufed with advan- 
tage. By occupying lefs fpace in the 
mouth than the inftruments in common 
ufe, it may be employed where they are 
inadmimble. B> The handle through 
which the fcrew A C is palled, by which 
the plate of iron D may be more or lefs 
feparated from the fixed plate E, by turn- 
ing the nut A. The plates D E fhould be 
fufficiently firm for refifling the preflure 
of the jaws, and they fhould be covered 
with leather or cloth to prevent the teeth 
from being injured. 

Fig. 2. Another form of a fpeculum for 
the mouth. G i7, Two firm iron plates, 
which being inferted between the teeth of 
the upper and under jaws, may be fepa- 
rated to any neceflary degree by turning 
the handle F. The farther extremity of 
the plate G is intended to comprefs the 

tongue, 



Explanation of the Plates. 411 

tongue, an addition which may be eafily 
made to fig. 1. 

Fig. 3. The inftrument in common ufe 
as a fpeculum oris, but it is fo defective 
that it can feldom be ufed with much ad- 
vantage. 



Plate LV. 

[Oppofite to page 208.] 

Fig. I. Forceps for laying hold of the 
lip in performing the operation for the 
hare-lip. It may be done with the fingers 
alone, but the parts cannot be fo neatly 
cut in this manner as when the forceps 
are employed. 

Fig. 2. A kind of cutting forceps, the 
invention of Dr John Aitken : They may 
be employed eitheflttn the hare- lip, or in 
the removal of cancerous affections of the 
lip : One blade of the forceps is a plane 
fmooth furface, while the other is furnifh- 
ed with a fharp cutting edge. In ufing 
this instrument the two blades muft be 
prefled againft each other with one hand, 
D d 2 with 



4ii Explanation of the Plates. 

with a force fufficient to divide the parts 
that are meant to be cut ; while the other 
hand is employed in fecuring the handles. 



Plate LVI. 

[Oppofite to page 224.] 

Fig. 1. ScifTars of a fize and ftrength 
fufficient for dividing the parts in the ope- 
ration for the hare-lip. It is not probable 
they will ever be generally employed, but 
I think it right to delineate a fize of the 
inflrument which by experience is found 
to anfwer. 

Fig. 2. Cutting pliers for the purpofe of 
removing fmall fplinters of bone where- 
ever they are met with. 

• 
Plate LVIL 

[Oppofite to page 236.] 

As the treatment of the hare- lip is a 
point of much importance, I have judged 
it proper to delineate the appearance of the 
difeafe, together with that of the parts in 

which 



Explanation of the Plates. 413 

which it is feated during the different 
ftages of the operation and cure. 

Fig. 1. A cafe of hare-lip in the upper 
lip. J, One of the incifores appearing in 
the centre of the opening, which ought to 
be removed before the operation, as a tooth 
in this fituation is very apt to interrupt 
the cure. B B, The unequal edges of the 
fifTure with which this affection is very 
commonly attended. 

Fig. 2. The appearance of the parts af- 
ter the edges of the fiffare have been re- 
moved and the pins introduced. C C, The 
edges of the cut, which ought to befmooth, 
equal, and exactly of the fame length on 
each fide, fo that when drawn together no 
inequality may be perceptible. The firft 
pin fhould be inferted near to the under 
part of the lip, and the upper pin near to 
the fuperior point of the fifTure. The pins 
reprefented in this figure are furnifhed 
with moveable fteel points, fo that the 
points may be taken away on the ligatures 
being applied, as is delineated in fig. 3. 
D d 3 which 



4 14 Explanation of the Plates, 

which exhibits the appearance of a hare- 
lip immediately after the operation. 

Fig. 4. A lip after the cure is com- 
pleted: D t Reprefents the appearance of 
the cicatrix, which in general mould be 
nearly a flraight line. 

Fig. 5. A flat pin for the operation of 
the hare-lip. The pin itfelf fig. 6. mould 
be of gold, and the point fig. 7. of fteel. 



Plate LVIII. 

[Oppofite to page 242.] 

Figs. 1. 2. 3. 4. and 5. Different forms of 
fcaling inftruments for removing tartar 
and other extraneous matter from the 

teeth. 

Figs. 6. and 7. Inftruments that may be 
employed either for burning the nerve of 
a tooth, or. for fluffing a hollow tooth 
with gold or lead. Fig. 8. may likewfe 
be employed for the fame purpofe, but it 
is more frequently ufed for fearching be- 
hind and between the teeth when there is 

any 



Explanation of the Plates. 41 j 

any fufpicion of a latent caries that is not 
readily difcovered. 

Fig. 9. Another inflrument for (luffing 
carious teeth. And, 

Fig. 10. A handle to which all thefe in- 
ftruments may be fitted. 



Plate LIX. 

[Oppofite to page 276.3 

Fig. 1. The inftrument commonly term- 
ed a key for extracting teeth. After a 
variety of alterations in the form of it, the 
one here delineated is the belt I have ever 
ufed. 

In fig. 2. the inftrument in common ufe, 
the claw is fixed, and can only be moved 
by taking out the fcrew by which it is 
connected with the inftrument ; but in this 
it may be moved from one fide to another, 
merely by preffing upon the nut A y by 
which the fpring B is raifed out of a nitch 
in a wheel which is thus rendered move- 
able, and in which the claw is fixed. D, 
The heel of the inftrument, which is 
D d 4 here 



41 6 Explanation of the Plates. 

here reprefented not only of a greater 
depth, but confiderably longer than it 
is ufually made : Of this length it is ap- 
plied to a confiderably extent of gums, 
by which the jaw is not fo apt to fuffer as 
when it is much ihorter ; and of this depth 
it a<5ls with more power than when of the 
ufual form. This part of the inftrument 
fhould not only be well poliflied, but it 
ought to be quickly covered with feveral 
plies of foft old linen, in order to render 
the preflure produced by it upon the gums 
as eafy as poflible. The handle E is fome- 
times made of iron ; but it anfwers better 
either of ivory or timber. 

Fig. 3. A claw bent in fuch a manner, 
that when the heel of the inftrument D is 
placed upon any part of the gums, the fe- 
cond or third tooth farther in the mouth 
may be pulled with it. This proves fome- 
times ufeful, where the gums oppofite to 
the affected tooth are particularly tender ; 
and it fliould always be employed when it 
jis meant to pull either of the two fartheft 
piolares of the lower jaw outwards ; for 

when 



Explanation of 'the Plates. 417 

when the common inftrument is ufed, the 
gums which cover the projecting part o£ 
the coronoid procefs of the jaw are always 
much lacerated. 

Fig. 4. and 5. Two claws of different 
fizes of the ordinary form. 



Plate LX. 

[Oppofite to page 291.3 

Figs. 1. and 3. Two inflruments much 
employed in different parts of Europe for 
extracting teeth. They do not, however, 
poffefs any advantage over the key inurn- 
ment ; and they are liable to this objection, 
that they cannot be ufed where it is necef- 
fary to turn a tooth towards the infide of 
the mouth. 

Fig. 1. d, The fulcrum, which ought 
to be well covered with fofc old linen. 
J5, The claw fixed to the handle E, by a 
fmall hole in the end of it, which receives 
a knob of a correfponding fize at C, and 
it is retained in its fituation by a move- 
able plate of polifhed iron D. The handle 

fliould 



41 8 Explanation of the Plates t 

fhould be wood, and all the reft of the in- 
ftrument of iron or fteel. Fig. 2. A claw 
with a confiderable degree of curvature, 
for extracting teeth at a greater depth in 
the mouth than the fulcrum can be pla- 
ced at. 

Fig. 3. F, The fulcrum. E, A ftraight 
claw fixed to the inftrument by a fcrew 
at H. I 9 The handle, which mould be 
of wood. 



Peate LXI. 

£Oppofite to page 285.3 

Figs. 1, 3. and 4. Different forms of for- 
ceps for extracting teeth. Fig. 3. is per- 
haps the moft ufeful of any. 

Fig. 2. Small differing forceps employ- 
ed in different operations in the mouth, 
as well as in other parts. 

Plate LXII. 

[Oppofite to page 293-] 

Fig. i. Teeth forceps with moveable 
claws. And, 

Fig. 



Explanation of the Plates. 4 1 9 

Fig. 2. A fulcrum to be ufed along with 
them, both defcribed in page 293. 

Fig. • An instrument for dividing the 
frenum linguae, defcribed page 33S. 

Plate LXIII. 

[T)ppofite to page 300.3 

Figs. 1.2. and 3. Different forms of a 
punch or lever for extracting fhumps of 
teeth. The method of uling them is de- 
fcribed page 300. Figs. 1. and 3. are the 
beft. They confift of two parallel plates 
of polifhed iron, which may be feparated 
more or lefs by preffing the moveable Ai- 
ders A B higher or lower. 

Figs 4. 5. 6. and 7. Different forms of 
files for removing inequalities upon the 
teeth. 



Plate 1X1 V. 

[Oppofite to page 361.] 

Figs. 1.2. and 3. Different forms of in- 
ftruments employed for concentrating 

found 



420 Explanation of the Plates. 

found in cafes of deafnefs, defcribed in 
page 361. 

Fig. 4. A fyringe of a proper fize for 
warning the meatus auditorius externus. 

Figs. 5. and 6. Inftruments for perfora- 
ting the lobes of the ear, defcribed page 
363- 



Plate LXV. 

[Oppofiteto page 372.] 

Figs. 1.2. and 3. Different forms of glaf- 
fes for drawing milk from the breafts of 
women. With figs. 1. and 3. the breafl: 
may either be fucked by the perfon her- 
felf, or by an affiftant ; and fig. 2. is a glafs 
cup, mounted with a bag of elaftic gum. 
J, The glafs cup joined to the bag C by 
the intervention of a brafs tube B. They 
are more particularly mentioned in page 

37 2 - 



Plate 



Explanation of the Plates, 421 



Plate LXVI. 

[Oppofite to page 374-] 

Fig. 1. An inftrument mentioned in 
page 371, for fupporting the head after the 
operation for the wry neck. ABC, A 
curved plate of iron fitted to the moulder, 
and fupporting another plate, to the top of 
which is connected the plate DEF, up- 
on which the head is meant to reft, and 
which therefore mould be covered with 
foft leather or cotton. GUI, A buckle 
and (trap for fixing the inftrument round 
the neck. 

Fig. 2. 3. and 4. Different kinds of cups, 
which may be either of ivory, lead, or fil- 
ver, for covering the nipples and protect- 
ing them from the cloaths, when they are 
either chopped or otherwife difeafed. The 
holes in their brims are for receiving pieces 
of fmall tape for fixing them round the 
body. 

Fig. 5. A broad flat needle, of a lancet- 
form, 



422 Explanation of the Plates. 

form for introducing cords or fetons iii 
different parts of the body. 



FINIS. 



DIRECTIONS to the BOOKBINDER. 



Plate XXXIX.to face page 21 



XL. 


39 


XLI. 


30 


XLir. 


57 


XLIII. 


74 


XLIV. 


109 


XLV. 


Ii7 


XLVI. 


120 


XLV1I. 


122 


XLVIII. 


126 


XLIX. 


144 


L. s ' - 


154 


LI. 


160 


LII. 


164 



Plate LI II. to face page 17O 



LIV. 


200 


LV. 


2C8 


LVI. 


124 


LVII. 


236 


LVIII. 


242 


LIX. 


' 276 


LX. 


- 283 


LXI. 


285 


LXII. 


293 


LXIII. 


- 3 co 


LXIV. 


36c 


LXV. 


372 


LXVI. 


374 



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